HomeMy WebLinkAboutSeptic Pumping Slip - 1365 Salem - 11/19/2024 - Septic Pumping Slip - 1365 SALEM STREET 11/19/2024 Commonwealth Massachusetts
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System Pumping
Record
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Form 4
OEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must besubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CK8R 15.351. -
A. Facility Information
| When
�m� out 1 System Location:
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2. System Owner
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Name
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Cbyitown 8tate ZipCode
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B~ Pumping Record
11/1S/24 1500
1. Date ofPumping D�� 2. (]uandt Pumped: Gallons
3. Component: El Cesspool(s) Septic Tank Tight Tank 0 Gneeeo Trap
n Other(describe):
4. Effluent Tee Filter present? Fj Yes El NV If yes, was it cleaned? F-1 Yes n No
5. Observed condition of component pumped:
CONDITIONGOOD
G, System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
Comp�ny
7. Location where contents were disposed:
GLSD