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
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