HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 793 FOREST STREET 10/2/2020 _ geef, fc0
Comm
onwealth of Massachusetts oC� .1) __
City/Town of t A �-)d o ve — Ho0oovVA
System Pumping Record of wovo
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 Location:
on the computer,
use only the tab 0 r �-�-
key to move your Addreae
cursor-do notP�
use the return �C V M O ( �
key. CHy/Town &ems _
�P Code
w 2. System Owner.
Nwm
l�l
Address(if different from location)
Cllylfown State
zip coft
Telephone Number
B. Pumping Record tom,
1. Date of Pumping —! 2. Quantity Pumped: - UG
Date GetOf>sa
3. Component: ❑ Cesspool(s) (�, Septic Tank El Tight Tank
❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
q O cA
6. System Pumped By.
Name
c'e 1 umping&Drain co.,wv Vehicle License Number
5 t3allber8 Park
Company NorthReadtng,MA MR
7. Location where contettts were disposed:
Cl 2D
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date