HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 97 COMMERCE WAY 10/28/2021 Commonwealth of Massachusetts RECEIVED
City/Town of __L. Y1Ck 0 yr b
a System Pumping Record TOWN HEALTH
DEPARTMENT
ER
HEALTH DEPARTivIENT
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, , 11 ,, `
use only the tab 1J�1
key to move your Address
cursor-do not A n(- p\j G i k` L+S
use the return City/Town !—� �+ State Zip Code
key.
m
2. System Owner:
w �-e_nCe_ J &:J: Cenfer . LI-L
Name
Address(if different from location)
City/Town State Zip Code
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Telephone Number
B. Pumping Record
1. Date of Pumping Date C ao a, n0)
2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) IVI 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:
6. System Pumped By:
A nCA.re_yJ
Name service Pumping&Dmin Co,Inc, Vehicle License Number
s Haft1patk
Company
7. Location where contents were disposed:
Ioil w1aI
ignature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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