HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 102 SUGARCANE LANE 6/8/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of JUN 0 8 2022
System Pumping Record Tod EACTH NORTH
AMENTER
Form 4 H
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
key to move your Addresscur _
use the
returndo IVY' ���� MIA OPH
use the return
key. City/Town State Zip Code
2. System Owner:
Name
,wn Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ' 2� 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 9Sepfic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present?z Yes ❑ No If yes,was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
(-,o C)
v
6. System Pumped By:
-
Nam Vehicle License Number
G,C-J Plu"bi iiA,
Company
7. Location where contents were disposed:
GAS
Signatud of H u er Date
Signature of Receiving Facility(or attach facility receipt) Date
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