HomeMy WebLinkAboutSeptic Pumping Slip - 10-11-2024 - Septic Pumping Slip - 1155 SALEM STREET 10/11/2024 Commonwealth of Massachusetts n ®ver
City/Town of Apdaer
FEB2o25
�- 1 System Pumping Record
._.... Form 4
DEP has provided this form for use by local Beards of Health. Other farms maybPd1ArQe4t
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. Systems`L'�ocation: �y an the computer, d..� _ _ _"use only the tab d
key to move your Address
cursor-do not ,
use the return ° -. . ... .._-_L . _ _ _ _ __...
key. City/Town State Zip Code
2. System Owner:
w _
Name
Address(if different from location)
City/Town State Zip Code
Teleph e Number
B. Pumping Record
on
1. Date of Pumping 14q 2. Quantity Pumped: _-lC� - _.
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank F1 Grease Trap
❑ Other(describe): __...._.. _._. __ . --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? F] Yes E] No
5. Observed condition of component pumped
.. : _._..__. ....... ..........
6. System Pumped By:
C
Name Vehicle License Number
Company
7. Location wh contents were disposed:
_.......... __._. _._.._- --------- _ _._.... ..__._..._
Si ur a Hauler Date
Signat f R ving°F6cility(or attach facility receipt) Date
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