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HomeMy WebLinkAbout- Septic Pumping Slip - 100 TUCKER FARM ROAD 9/7/2018 Commonwealth of Massachusetts RECEIVED =r� City/Town of s = System u pig Record c� �'K)Rl�utq,4t)(ALL Form 4 ,� � w :iw �iul"� 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, use only the tab ) f'" " key to move your Address cursor-do not ?,r, use the return key. City/Town State Zip Code 2. System Owner: Name reran , Address(if different from location) _------------._-_ ----------___._ __-.-_._.__.------ 0 ty/Town state Zip Code Telephone NumberT B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank © Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Ye No If yes,was it cleaned? ® Yes ❑ No 5. Observed condition of comp nent pumped: 6. System Pumped By: Name Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record Page 1 of 1 A"