HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 251 GRANVILLE LANE 12/6/2021 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 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,
use only the tab a S V
key to,move your Address
cursor-do not NU �H i tq,•%LlC t
use the return City/Town �`
key. State Zip Code
2. System Owner:
m� -D k-
Name
Ell-
(if different from location)
Cityrrown State Zip Code
S �F- -7
Telephone Number
B. Pumping Record
1. Date of Pumping Date 1 2/ 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co ition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where cont nts were disposed:
ZZ4 Lle
1
Signature of Hai r Date
Signature of Receiving Facility(or attach facility receipt) Date
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