HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 SUNSET ROCK ROAD 11/2/2021 Commonwealth of Massachusetts
City/Town of
System Pumping Record •
r Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may '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 Inform' ation
1. System Location: Left/Right front of house, Left I t rear of hous 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
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
gab 0
Name
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? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed concIltiorl of component pumpe
6. System Pumped B
N.,jMTESON ENTERPRISES,INC. Vehicle License Number
111 ARGILLA ROAD
Comp DOVER,-MN01-810 -
7. Location where ontents were dis osed:
C� - -�,-
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1