HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 47 BOXFORD STREET 6/12/2024 417 of lVor
Commonwealth of Massachusetts V
City/Town of
lz
r System Pumping Record
_. Farm 4
DEP has provided this farm for use by local wards of Health. Other farms may be usec9!041he
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 Informationy
Important:when
filling out forms 1 S stem Location
on the computer,
use only the tab _. ----- _ '_. _ '
key to move your Address
cursor-do not
r --- - -- -
use the return --._ _......._._.____.__.__...-__---� _.. ........_._____--_ -_-
key. City/Town State Zip Code
2. System Owner: e
k d\,p .w
Name
roar
Address(if different from location)
...... ...... _....-
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Ekieptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Na If yes, was it cleaned? ❑ Yes ❑ No
5 Observed con tion of component pumped:
676
6. System Pumped By:
Name Vehicle License Number
Company
7. Location wherq contents were disposed:
r .
e
...... ....._.._._._ _. ...................._. ..._.. _ .._... .__............._.. _ _......_... -....... ........_._.....
Si ure Hauler Date
Signatur of e ' dng Facility attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1