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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 MILL ROAD 9/3/2020 RECEIVED S� Commonwealth of Massachusetts City/Town of ®ram A Io'vc oFNpR(HAN©LIVER i System Pumping Record ZDWN ieALTHpEPARTMENT r 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 1. System Location: forms on the 2 Mill () computer,use only the tab key Address y V to move your ► Anduer '• 1 O,84 S cursor-do not City/Town State• Zip Code use the return key. 2. System Owner: VQ Joyc1an Name Address(if different from location) i Citylrown State Zip Code Telephone Number B. Pumping Record la 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) f 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: wm-k nq COodIl- o h 6. System Pumped By: Name )RE Vehicle License Number Company d 7. Location where contents were disposed: Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1