HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 HOLLOW TREE LANE 6/8/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of WN OF NORTH
JUN 0 g 2022
System Pumping Record TO HEALTHEPARTMENTER
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 3S
key to move your Address
cursor-do not No� Ma 618`ts
use the return Cityrrown ate Zip Code
key.
2. System Owner.
Nyc,�,-�-
Name —
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Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
te
1. Date of Pumping 22 Date 2. Quantity Pumped: Gallons��
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- --- --
4. Effluent Tee Filter present? ❑ Yes D No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle Incense Number
Company
7. Location where contents were disposed:
SilgnaXini of uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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