HomeMy WebLinkAboutSeptic Pumping Slip - 10/3/2024 - Septic Pumping Slip - 437 SUMMER STREET 10/3/2024 Commonwealth of Massachusetts
1volth
City/Town of _& ave
System Pumping Record
ti M_ Form 4
DEP has provided this form for use by local Boards of Health. Other forms ed, but the
information must be substantially the same as that provided here. Before using thl ck with your
local Board of Health to determine the form they use.The System Pumping Record mustt#ted to
the local Board of Health or other approving authority within 14 days from the pumping date in 4
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab _
key to move your Address
cursor-do not
use the return __ ____ ..__ _ -Code
key. "City/Town State Zip Code
2. System Owner:
r �
r r'
Name
err
Address(if different from location)
_._...._.._...-------...__.--__ - —-----...............___....--_——----.... ------ ................ -- -- --
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ._._ __ _..-___ 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - --___--- __-_----- —
4. Effluent Tee Filter present? lr Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed Condit' of component pumped:
........... --------------- ...........
6. System Pumped By:
e / Vehicle License Number
ompany
7. Location whey ntents were disposed:
---------- - - ---_..---.............__...___..__.-------__.._....____....._ _....------._..- - - ----
.................. _- --------_._
Sig Haulers Date
Signature of Receiyjing Facility(or attach facility receipt) Date
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