HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 34 LIBERTY STREET 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 Locatiordi ightTront of house,'Left/Right rear of house, Leff/right side of house, Left
Right side of building, Left/ Right front of uilding, Left/ Right rear of building, Under deck
use only the tab -
key to move your Address
cursor-do not
use the return —
City/Town State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
City/Town State t ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): —- - ——
4. Effluent Tee Filter present? ❑ Yes LINO If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pum d:
6. System Pu -ri B
Na[IBATESON ENTERPRISES,INC. Vehicle License Number
111 ARGILLA ROAD
CompA�IDOVER; A01810
7. Location wh cotents�re disosed:
Signature of Date
Signature of Receiving Facility(or attach facility receipt) Date
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