HomeMy WebLinkAboutSeptic Pumping Slip - 742 Boxford St - 11/15/2024 - Septic Pumping Slip - 742 BOXFORD STREET 11/15/2024 Commonwealth �� Massachusetts
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Form 4
DEP has provided this form for use hv local Boards ofHealth. Other forms may bmused, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board Vf Health bo determine the form they use. The System Pumping Record must be submitted to
the |oom| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CK8R 15.351
,
A. Facility Information
Important:When
filling out forms 1 System Location: _
on the computer,
use only the tab 742BOXFOROST
hey to move your Address
cursor-do not
ND�THANDDVER MA D184�
use the return
- ---------------_---�---------_ -- _-=
key. City/Town State Zip. '�� — ---'-----
' .
2. System Owner:
~---^ CHR|SHAGERTY
cuy/ru°n SBom ipCode
elephone Number
B. Pumping Record
11/15/24 15OO
1. Date of Pumping bate2. Quantity Pumped: G all uns
3. Component: Cesspool(s) Septic Tank R Tight Tank El Grease Trap
[] Other(describe): --------
4. Effluent Tee Filter present? [l Yes F] No |f yes, was itcleaned? R Yes Fl No
5. Observed condition Vf component pumped:
GOODC0ND|T|ON
6. System Pumped By:
JAY CURRIER H79406
mame Vehic|eLioeneowunnber
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
sigXnato auler Date
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