HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 OLYMPIC LANE 11/3/2022 Commonwealth of Massachusetts
—( City/Town of 011
System Pumping Record Novo 3ti o�Ea
Form 4 owN o f\,ApE PR ME01
DEP has provided this form for use by local Boards of Health. Other YonSay 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 Address
cursor-do not `� Lle
use the return City/Town / State key. --Zip Code
2. System Owner:
Name
-1)
_
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping / 1000
Date
p g 2. Quantity Pumped:
Gallons
3. Component.- ❑ Cesspool(s) f/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Nor- If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
CZ�'�t
Company
7. Location where ontents were disposed:
,'
C'c-t62
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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