HomeMy WebLinkAboutSeptic Pumping Slip - 9-12-2024 - Septic Pumping Slip - 94 BOXFORD STREET 9/12/2024 _ Commonwealth of Massachusetts o o "' rt n.�.. aver
City/Town of
l� System Pumping Record FEB .. 4 2025
Form 4
DEP has provided this farm for use by local Boards of Health. Other forms
information must be substantially the same as that provided here. Before using this form, c 0 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, -
use only the tab - _ .. _-._
key to move your Address
cursor-do not
use the return --__ __.... _. . 5 '_._ . __._.__.____.__........_._ -- -.._._ -------
key. City/Town State Zip Code
VQ 2. Wyt em Owner; 1 !" _.
16X
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping late ___._ .... 2. Quantity Pumped; alions _. __....
3. Component; n Cesspool(s) LJ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe); _._ ........_ ... .............
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co�frditlon of component pumped;
12__ ��r -. ... ..........
6. System Pumped By;
gam Vehicle License Number
Company
7. Location where contents were disposed;
-. ---
Srgnd or of auleF Date
Signat savan9- acll'ity(or attach facility receipt) Date
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