HomeMy WebLinkAboutSeptic Pumping Slip - 4-18-2024 - Septic Pumping Slip - 121 CAMPBELL ROAD 4/18/2024 i' of
Commonwealth of Massachusetts
_ City/Town of 2025
x r
System Pumping Record e
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used,buY'ttle
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, i" ,t C 0 +
use only the tab
key to move your Address
cursor-do not i6 B-
use the return _. .._t . _. .._.._.._.. -- --
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
73 C1
Telephone Number
B. Pumping Record
[Gsoo
1. Date of Pumping - _ - 2. Quantity Pumped:
Da 11 te Gallons
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 Q No
5. Observed condition of component pumped:
6. System Pumped By:
-! e- 1-70
� ___ '� _Name Vehicle License Number
Company
7. Loc
ationtents were disposed:
_ ...._ ---__. _. .-Sig _.. .... ...-_ . .._,11 D 11 ateSi Facility(or,attach facility receipt) Date
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