HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 167 DUNCAN DRIVE 11/2/2021 Commonwealth of Massachusetts
City/Town of
System Pumping Record
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.
A. Facility Information
1. System Location: Left/ ' t front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/ Right front of building, Left/ Right rear of building, Under deck
use only the tab
key to move your Address t
cursor-do not l'
use the return - - ---- - -
City/Town State Zip Code
key.
2. System Owner: o
Name
- _ - - - - - -
mtm '
Address(if different from location)
City/Town State ` �5�Zip Code
t/v- r
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 0,48'eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -
4. Effluent Tee Filter present? ❑ Yes a4 o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component umped:
6. System Pun`ped"By:
�U..�.� M A f= 5'8---x
NanigATESON ENTERPRISES,INC. Vehicle License Number
111 ARGILLA ROAD
CompA�IDOVER, MA 01810
7. Location where contents we'
disposed:
Signature f Date
Signature of Re eiving Facility(or attach facility receipt) Date
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