HomeMy WebLinkAboutSeptic Pumping Slip - 4-18-2024 - Septic Pumping Slip - 64 BOSTON STREET 4/18/2024 °W of North
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Commonwealth of Massachusetts F
EB
City/Town of 42025
w..❑
eft e5 stem Pumping Record
- - Form 4
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
n'on the comuter,
filling out forms System OCa to
p
use only the tab
key to move your Address
cursor-do not e-e
use the return ""` ---- __..__- - _.-... -- ---- - - - - -------
key.
City wn Sta e Zip Code
2. System Owner:
f
Name
_- - -_
Address(if different from location)
- ..............-- _... - ---------- -------. _ ..
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping date'� ._. _..__._-.-_ 2. Quantity Pumped: Gal,ns
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): . _
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
---_--- ----- - --------------------...---- — --- -
6. System Pumped By:
A111
1
--- - - -_ - - _ . _. .
me Vehicle License Number
Company
7. Location whey ntents were disposed:
- - - _----
Sign t uler- - Date
Signature o Re eiving F cielit�yyr attac facility receipt) Date
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