HomeMy WebLinkAbout- Septic Pumping Slip - 120 CRICKET LANE 2/4/2019 Commonwealth of Massachusetts
City/Town of
� System Dui r
Fortin 4
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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.
1
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✓ 7' " - '�
key. City/Town State Zip Code
' 2. System Owner:
Name
rrur
Address(if different from location)
City/Town State Zip Code
'telephone(dumber
B. Pumping c r
1. date of Pumping k 2. quantity Pumped: ' a
Cate Gallons
3. Component: E] Cesspool(s) `"`Septic Tank Ej Tight Tank ® Grease Trap
M Other(describe):
4. Effluent Tee Filter present? ❑ Yes U3`No If yes,was It cleaned? ® Yes 0 No
5. Observed condition of componnt pumped:
� a
6. System Pumped By:
Name { i Vehicle License Number
Company
7. Location where contents were disposed:
� .m . E ..w>
„a
Signature of Htuler Crate
Signature of Receiving Facility(or attach facility receipt) Cate M i
t5form4.docq 11/12 System Pumping Record•Page 1 of 1