HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 625 BOXFORD STREET 8/16/2019 UVCommonwealth of Massa
City/Town of ch usetts
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health,Other forms may b
Information must be substantially the same as that provided here. Before usingthis
local Board of Health to determine the form they use. The System Pumping Record
form,used, but the
the local Board of Health or other approving authority within 14 days from the um Pumping
d check with your
accordance with 310 CMR 15,351. must be submitted to
p p ng date In
A, Facility Information
Important:When
filling out forms 1, System Location:
on the computer,
use only the tab
key to move your Address G S
cursor-do not
use the return -
key. City/Town
State
rt 2. System Owner: ZIP
Code
Name Q `�
Address(if different from location)
City/Town
State
Zip Code
B. Pumping Record
1. Date of Pumping
Date 2, Quantity Pumped:
3. Component: Gallons
❑ Other(describe):❑ Cesspool(s) Q Septic Tank ❑ Tight Tank Grease Trap
4. Effluent Tee Filter present? ❑ Yes ❑ No
If yes, was it Cleaned? ❑ Yes ❑
5. Observed condition of component pumped: No
----—--_
6. System Pumped By:
Name
Vehicle License Number
Service Pum in &Drailt
Company 5Hal rgPark
7• Location where co North Readjq,MA018c;
titents°avet^e disE3vsed:
y L5
Sign,Zre of Hauler ��j C_:Dat�_-
DateSiBnaturo of R000iving aclllty(or attach facility recelpt) Dat a"""~—
t5form4.doc-11/12
System Pumping Record•Page 1 of 1