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
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