HomeMy WebLinkAboutSeptic Pumping Slip - 4-18-2024 - Septic Pumping Slip - 498 SALEM STREET 4/18/2024 Tow
f Massachusetts n °u etts n
Commonwealth o assa s ever
ry
City/Town of Avid 0�e
System Pumping Record
FEB4 2025
Form 4
He It
DEP has provided this form for use by local Boards of Health. Other forms may be Laqp&ft �g
information must be substantially the same as that provided here. Before using this form, check wl�th";our
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, ( l m ,
use only the tab 1t Ifir ,
..
key to move your Address _
cursor-do not 6 l
use the return ------____--
key. City/Town State Zip Code
y
� e r1
�. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping --- 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank n 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:
_ C ..
6. System Pumped By � t
Name Vehicle License Number
4i R .
Company
7. Location re contents were disposed:
Sig o HauTdr-...w Date
Signature of
ce g Facility(or attach facility receipt) Date
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