HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1248 SALEM STREET 5/5/2025 Commonwealth of Massachusetts -7b W17 Of ho
City/Town of r
kA y
.............. System Pumping Record 52025
Form 4
DEP has provided this form for use by local Boards of Health, Other forms may be usI a
information must be substantially the same as that provided here. Before using this form, 'T'eftgyour
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 Sc'Vel;i
S --- ---------....... ------ ------
key to move your Address
cursor-do not
use the return
key. City/Town S ate Zip Code
2. System Owner:
Name
fi
................... ...................................---—------------------- ............. .............
Address(if different from location)
State q Zip Code
-Telephone Num-ber---
B. Pumping Record
112, 'S
1. Date Of Pumping Date 2. Quantity Pumped: Gallons
1 Component: M Cesspool(s) U"6eptic Tank R Tight Tank ❑ Grease Trap
R Other(describe): - ----------- ------------
4. Effluent Tee Filter present? E] Yes F] No If yes, was it cleaned? ❑ Yes R No
5. Observed Condit* f component pumped:
CFO 7 0
............. ------- .......... ...............-----------------
6. System Pumped By:
7 d
Name r Vehicle Li I Gense Number
Qompany 17'
7. Loc tion where tents were disposed:
---------- -----------
........... -----------
............ -------------------
Signa e of Hau er Date
Signature of 4ec i Facility(or a*h facility receipt) Date
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