HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 104 CARLTON LANE 6/17/2020 RECEIVED
Commonwealth of Massachusetts 3UN 17
City/Town of ar4? GT
System t e m Pumping 1 Mq ?OWN 0T )EPA,?
MEN ER
Y mping Record im4
�\ ! Form 4
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 Locatioq
on the computer, J C //t
use only the tab / C, y l� <i t^//—Z,/) -- Z�
key to move your Address , ---- ---__ _
cursor-do not
use the return
key. Cily/Town _
2. Sy§tem Owner: State Zip Code
Name
arm
Address(if different from location)
City/Town State Zip Code
Telephone Number '
B. Pumping Record
1. Date of Pumping pate --- 2• Quantity Pumped: �`c1
Gallons
3. Component: ❑ Cesspool(s) Septic Tank g ❑ Grease Trap
[� ❑ Tight Tank
❑ Other(describe): ---- — ----_ __
4. Effluent Tee Filter present? ❑ Yes P�,No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
& System Pumped By:
Name 5HaUbergPark Vehicle License Number
North Reading,MA 01864
Company .K.y a .: --
7. Location where contents were disposed:
Signat,, f Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112
System Pumping Record•Page 1 of 1