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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 208 OLD CART WAY 11/2/2021 Commonwealth of Massachusetts City/Town of System Pumping Record OP Form 4 DEP has provided this form for use-by local Boards of Health. Other forms may beused, 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/Right front of house, Left/Right rear of house, Left/ I h side of hous Left/ Right side of building, Left/ Right front of building, Left/Right rear of building, Under ec use only the tab key to move your Address cursor-do not use the return — key. City/Town State Zip Code � 2. System Owner: Name nam Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): - - — 4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No 5. Observed condition of component purpped: 6. System Pumped By: Nf JL� P1,A IF SS�►I' NangATESON ENTERPRISES,INC. Vehicle License Number 111 ARGILLA ROAD CompA�DOVER,MA 01810 7. Locatio ere conte'w disposed: al Signatur f u r Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1