HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 217 GRAY STREET 6/12/2024 To Wn Of Jvotth
Commonwealth of Massachusetts aver
City/Town of t
Syst
em Pumping Recorc!
µix p '�
°.; Form 4
DEP has provided this farm for use by local Boards of Health. Other forms may be u
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
fining out forms 1, System Location:
on the computer, ( r
use only the tab .. _1 h
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
r n
Name
11
Address(if different from location)
Cityil own State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping ............ 2. Quantity Pumped:
Crate Gallons
3. Component: ❑ Cesspool(s) eptic Tank E] Tight Tank ❑ Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned"? F ] Yes ❑ No
5. Observed con ition of component pumped:
_ ..... , . _............_ _---
6i System Pumped By:
� LOCO, � ,
X... __ ._... ___ _._.._ _ _ ------- -_-.
Name „ yypyp pg Vehicle License Number
Company
7. Location wh contents were disposed:
Sig ur o Hauler"" Crate
Signatu calving Fa '' (or attach facility receipt) Crate
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