HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 215 GRANVILLE LANE 12/6/2021 Commonwealth of Massachusetts
City/Town of
.° System Pumping Record
Form 4
M
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When _—
filling out forms 1. System Location:
on the computer, 1 (—
use only the tab � 7 I J C3 �Gi I1 i I( e I
key to move your Address
cursor=do not Alo A ►ido ye rT �/Y_6
use the return !Town
key. Ci ty State Zip Code
2. System Owner:
S e n 4e r
Name
rerun
Address(if different from location)
City/Town State Zip Code
7— ISS3F
Telephone Number
B. Pumping Record
1. Date of Pumping Date l I 22 21 2 000
. Quantity Pumped: f-
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes V No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditio of component pumped:
6. System Pumped By:
Name Vehicle License Number
�y rG`CZc�S � -E-�"C
Company
7. Location where conT //
ts were disposed:
�� ✓ems
G-eo!(ge
Signature of Haig6r Date
Signature of Receiving Facility(or attach facility receipt) Date
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