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HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 145 CARLTON LANE 5/8/2020 Commonwealth of Massachusetts 0 IE 0 d F City/Town of System Pumping Record MAY F - Form 4 DEP has provided this form for use by local Boards of Health. Other fbr ns may,00 u gd_bW.t e___...._ 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, — I/ use only the tab L� 7 Lea 1 y1 Vl key to move your Address cursor-do not use the return key. CityFTown State Zip Code 2. System Owner: I^ f lS��r1 sC (,���2 n JeG fC Name Address(if different from location) CitylTown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping c1_ 10 -20 2. Quantity Pumped: J Date Gallons 3. Component: ❑ Cesspool(s) �ptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes pQ No If yes,was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pump d: 6. System Pumped By: Name r Vehicle License Number �0naC -z Company 7. Location where contents were disposed: Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 M 1