HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 12 BARCO LANE 9/3/2020 Commonwealth of Massachusetts
RECEN'E )
City/Town of '�®�cl ;\060Ver p 0 20 t1
System Pumping Record TOM 00 t40KjHPINE R
JY Form 4 H�
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 the i C-D
computer,
r,use 1 [��t i
only the tab key Address j
to move your Nrly-- 1 Q 1(Z(`1 f�vc V M A
cursor-do not City/Town 1 V� `( t_l_1�11 L� t State Zip Code`
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record � �
1. Date of Pumping LA-1' /� a 2. Quantity Pumped: I
Date Gallons
3. Type of system: ❑ Cesspool(s) J 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:
030y'Y'A g c'and aeon
6. System Pumped By:
Name��V Vehicle License Number
Company
7. Location re contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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