HomeMy WebLinkAboutSeptic Pumping Slip - 183 VEST WAY 1/9/2018 Commonwealth of Massachusetts
City/Town of .
0
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
filling out forms 1. System Location:
on the computer, q
use only the tabs L
key to move your Addre s —.._—....___
cursor-do not
use the return CI /Town
key. ty State Zip Code
2, System Owner:
r�
Name
Address(if different from location)
- - --
City/Town State– _ Zip Code
Telephone Number
B. Pumping ecord
1. Date of Pumpingpat$ 2. quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ®r'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ other(describe): - _. _.a_._.
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: i
6. System Pumped By:
Name 4 Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Maur bate - -
i
Signature of Receiving Facility(or attach facility receipt) Date
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