HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 93 CRICKET LANE 2/3/2022 AECE�VEG
Commonwealth of Massachusetts
City/Town of FEB 0 3 2022
System Pumping Record
Form 4 TOWN OF NORTH
TMENT R
' e HEALTH DE
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 r
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 Zip Code
12
Telephone Number
B. Pumping Record
1. Date of Pumping IC)- 2. Quantity Pumped: -�
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? J�f Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component umped:
�C1�
6. System Pumped By:
Name , ' Vehicle License Number
i3 o ro, c z e -S s e x-,4,-c
Company
7. Location where c ntents were disposed:
6
Signature o auler Date
Signature of Receiving Facility(or attach facility receipt) Date "
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