HomeMy WebLinkAboutCesspool - Septic Pumping Slip - 134 GREAT POND ROAD 6/8/2022 rIECEIVED
Commonwealth of Massachusetts
City/Town of JUN 0 8 2022
System Pumping Record ToHE c: NORTH DEPARTMENT
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Form 4 HEALTH DEPARTMENT
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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 isU I
I �c4,- 11 'POrG
key to move your Address 1 _
cursor-do not N6. &—A, e-
use the return City/Town State Zip Code
key.
2. Syste`mr Owner: .
V tldntcc- Mon c.(4
Name
nem
Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: )�!rCesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- ---- ---—-- — ---
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes No
5. Observed condition of component pumped:
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6. System Pumped Byz
T`rL G,��d w(09 -l-q o
Name , Vehide License Number
Clad ►Jtu�b�
Company
7. Location where contents were disposed:
6�S D
Sig �Mau Date
Signature of Receiving Facility(or attach facility receipt) Date
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