HomeMy WebLinkAboutSeptic Pumping Slip - 2024-07-18 - Septic Pumping Slip - 1300 SALEM STREET 7/18/2024 n Of
Commonwealth of Massachusetts oVIarch AnUOVer
City/Town ofArdbiely-
4 2025
System Pumping Record
` Form 4
the
nt
DEP 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 be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms System
on the computer,
use onl '.
Se Location:
y the tab -----
key to move your Addr;
cursor-do not
use the return -------- — __. _...._......------ = - --- .-.___ __- --------
use City/Town State Zip Code
2. System Owner:
�.......... .. _ ..... ................_ ........ ...... . _._ __.._-.._.......
Name
e,
Address(if different from location)
—---- - - ----------------------- --.- - -------------------. -----_-- ---------- -
City/Town State Zip Code
Tel;2h,
;Numb
B. Pumping Record
1. Date of Pumping ...............- - --.:_._.....__..._. 2. C�uantity Pumped; _._..........
.__..._........_...........
._._..._....._._-_.---
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ Na If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. �tem Pumped By;
t,
Name r Vehicl Lic;nse-Number
I m-o j A�A-�--6,2 a N—
ompany ✓
7. Vacation where contents were disposed:
Signatu o Date
__ Livinity
--._ignatureofattach facility receipt) Date
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