HomeMy WebLinkAboutSeptic Pumping Slip - 78 Spring Hill Rd 12-6-2024 - Septic Pumping Slip - 78 SPRING HILL ROAD 12/6/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
lug Form 4
DEP has provided thitform 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 CIVIR 15.351
A. Facility Information
important:When 'Own of/VOdh And
filling out forms 1 System Location:
on the computer,
use only the tab
key to move your
Address 141 '
cursor-do not
use the return
key. cityrrown state
Code
2. System Owner. Health D"p
VQ epartMent
Name
GA
Address(if different from location)
Zkif�rown State
13. Pumping Record TZip Code
elephone Number -
1. Date of Pumping
_L _'4 CCO
Date 2, Quantity Pumped: _dali`o'_ns
3. Component: 0 cesspooi(s) Septic Tank El Tight Tank ❑ Grease Trap
El Other(describe):
4. Effluent Tee Filter present? F-1 Yes 0 No If yes, was it cleaned? n Yes El No
5. Observed,condition of component Pumped:
& System Pumped By:
Y.
Name�
VehideUcense Number
-company
7. Location where contents were disposed:
ka
PS
(T
f Hauler
✓ Date
signature of Reclving Facility(or attach facrility receipt) date __ _._
t5fbm'4.doc-11/12
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