HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 843 JOHNSON STREET 8/15/2024 Commonwealth of Mass
achusetts 4/7 Ofn aVer
w City/Town of -VA ma'Ode4
System Pumping Record 025
Form 4 Health
DEP has provided this form for use by local Boards of Health. Other forms m a but the
information must be substantially the same as that provided here. Before using this o eck 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 CfVIR 15.351.
A. Facility Information
Important:When
filling out farms 1. System Location:
on the computer,
use only the tab ..... _
key to move your Address
cursor-do not 9�t
use the return "..N _ ._............. .. ..._ _ _.._. .. ...
key. City/Town State Zip Code
2. 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: [-1 Cesspool(s) Septic Tank ® Tight Tank Q Grease Trap
❑ Other(describe): _ _ _....... .. ......
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? [l Yes (l No
5. Observed con "tion of component pumped:
System Pump BY w (TM �`°
5. ys
� � Vie..
Name Vehicte License Number
Company
7. Lto'",
ntents were disposed:
s Datag F y(or attach facility receipt) Date
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