HomeMy WebLinkAboutSeptic Pumping Slip - 102 WINTERGREEN DRIVE 1/9/2018 Commonwealth of Massachusetts
City/Town of 1L11L-k\ A-rd-W ,,
System Pumping Record
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 CMR 15.351.
A. Facility Information
Important:When
tilling out forms I. System Location:
on the computer,
use only the tab D-a 03 tVAtjeA (r1 I'"CJ-0—
key to move your Ad ress
cursor-do not
use the return CI !Town C
key, tY State Zip Code
2. System Owner:
Name
Address(If different from location)
City/Town State Zip Code
WV
Telephone Number
B. Pumping Record
1. Date of Pumping flare 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) M Septic Tank ❑ 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::n
Name Vehicle License Number
n
Company
7. Location where contents were disposed:
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
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