HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 55 PHEASANT BROOK ROAD 9/3/2020 Commonwealth of Massachusetts RECEIVED
City/Town of woe,( SEP 0 S ?020
� 4 System Pumping Record TOWN OF
AND
VER
HEALTHForm 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 1. System Location:
forms on the n
computer,use i
only the tab key Address
to move your
cursor-do not w0b
use the return City/Town State Zip Code
key. 2. System Owner:
an
Name
Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record 1 �
1. Date of Pumping Date o 2. Quantity Pumped: G Sno
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
or
6. t Pumped By:
Name Di Vehicle License Number
Company
7. Location re co to s ere disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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