HomeMy WebLinkAboutSeptic Pumping Sllip - 06-19-2024 - Septic Pumping Slip - 521R SALEM STREET 6/19/2024 ivo
Commonwealth of Massachusetts Town rah must
City/Tow n of Fg 02
System Pumping Record
w / Form 4 Health
DEP has provided this form for use by local Boards of Health. Other forms may be s p
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 1. System Location:
on the computer, C"
use only the tab .__. _
key to move your A dress
cursor-do not Epp
Use the return __.._:.... - - ... «,_ .... - ---- .....
key. City/Town State Zip Code
2. System Owner:
&, r)
Name
Address(if different from location)
City own--------- State Zip Code
."" . .._-
Telephone Number
B. Pumping Record
1. Date of Pumping _ __-- 2. Quantity Pumped: -- .
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Q Other(describe): ..
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con lition of component pumped:
_..... ._..._. _ .... ._. --- ----_...
6. System e By: tl
Vehicle License Name � h Number� 1
ompany
7. Location where contents were disposed:
%ofRe
Dly
......._ ._
Sign Gate
_. _ __._ .._..11
Signattach facility receipt) Date
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