HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 459 SALEM STREET 5/29/2025 I UW1 I U1 1,4ul Ll I rAI IUV V--I
Commonwealth of Massachusetts MAR - 2 2026
City/Town of
S System Pumping Record Health Department
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 CIVIR 15351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, / I
use only the tab -.VS-Y 5),le4op, -------------
key to move your Address
cursor-do not /VA
use the return .............. ---------- --------------------
key. City/Town State Zip Code
2. System Owner:
MMIelr
�
Name
-Address-Cif different from location)
_-——------------- ........... -------------------
City/Town State Zip Code
-----------
Telephone Number
B. Pumping Record 0115-
1. Date of Pumping ......................... 2. Quantity Pumped:
Date Gallons
3. Component: F] Cesspool(s) 21"Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Ea"YesE] No If yes, was it cleaned? K3Yes n No
5. Observed condition of component pumped:
6. System Pumped By:
W7 0
7)
-2� J
.............. -------- t -----------
Name A C Vehicle License Number
T'rt , �/-d
.-I ),. "',
--- ----- . ................. -------
6o—Mpany-----
7. Location wh contents were disposed:
.. .. ......
ignatur f H er Date
Signature cility—(or-a-t- -- ----ta-chfa—cilityr--e-cei--p-t-)----- Date
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