HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 WHITE BIRCH LANE 7/19/2021 _P _ Commonwealth of Massachusetts R,C�IV5D
City/Town of - +h Av)Gt
System Pumping Record �HANoo
Form 4 100 HOE p,RZME11
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, -7
use only the tab r (,L}'r t "
key to move your Address -- - -- -
cursor- not I A J �,_
use the return
urn Cit /Town
key. y State Zip Code
2. System Owner:
a k
rn-Fri v lei
Name -
rnuq
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons - - -----
Date
3. Component: ❑ Cesspool(s) Dr Septic Tank ❑ 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:
�c
--
6. System Pumped By:
C) LI-0
Name 411,11doePUMPiAB&Dwaco�.I= Vehicle License Number
____ 5 Hallber�Par�
Company Roet4W—O 8 44
7. Location where contents w re disposed:
r7l � ai � � _
S-(gnatu 6fn6ul Date
-------- �----- — --- -------
Signature of--.Receiving.- Facility(or attach facility receipt) Date
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