HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1190 SALEM STREET 4/9/2025 Commonwealth of Massachusetts Town Of
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City/Town of
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System Pumping Record 52025
Form 4 ,
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DEP has provided this form for use by local Boards of Health. Other forms may beuRqMent
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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
filling out forms 1. System Location:
on the computer, -------------- __....__ �..- -..-.__
use only the tab
_.___�___.....___..__...._.....___....._.___._.._..
key to move your Address -
cursor-do not
use the return ---..._ t __— /.. .. G _.t... _._..._...-- ---..
key. City/Town State Zip Code
2. System Owner:
Name
r�rro
--------- ____. ___-... . __...__. - ......__ .__.._ _....... _. _.._. . ........ . ... . _..... _
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping — ---- — 2. Quantity Pumped:
Gate Gallons
3. Component: ❑ Cesspool(s) ❑SepticnTan ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No' If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
--....__-_..___.._.____....___----__.___._.______._____...._.__...__...._.____-------___.._._._.__.. ..---.._.___----..._.___------._.__.._
6. System Pumped By:
... _... .-.__._ ......__.._.....--- _ ---..._ - -- __.._..._ _ .._........................-._-_. .._ _..... ..
Name Vehicle License Number
Company
7. ..Location where contents were disposed:
-
__.__ _ _.... .... --- _...
Signature of He er.. Date
___.......
_____.______...._._.------�____.__.
Signature of Receiving Facility(or attach facility receipt) Date
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