HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1020 SALEM STREET 4/17/2025 awn of NOrth An(10 iler
1Z, Commonwealth of Massachusetts APR 23 2025
City/Town of AL-) ...1.. , )C 0 J
System Pumping Record Hea/th Departr
nerlt
Form 4
DEP has provided this form 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 CPR 15.351.
A. Facility Information
Important:When
filling out forms I. System Location:
on the computer, U, (,�\ W
use only the tab .1 1-------
key to move your Ali"
cursor-do not AV16 AA
use the return ............j ................ .......
key. City/Town State Zip Code
Z System Owner:
Oki
Name
. ......... .. .................... -------....................................... ...............
Address(if different from location)
---
City/Town-------- -s—tate 22 Zip
,37_
Telephone Number
B. Pumping Record
1. Date of Pumping Date I I I -------- -- -712 2. Quantity Pumped: Gallons
3. Component: M Cesspool(s) Do, eptic Tank F1 Tight Tank F-1 Grease Trap
F-1 Other(describe): ....................__...............
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? M Yes R No
5. Observed condition of component pumped:
........... -----------------____
6. System Pumped By: _7(_
(N d \AJ(oq, I
............
-Name Vehicle License Number
f WVO
Company
7. Location where contents were disposed:
S'
---------------- .......... ..............
Si ure, Hauler Date
Signa ---------
attach facility receipt) Date
CQ,o,f ngfG"
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