HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 OLYMPIC LANE 10/7/2022 Commonwealth of Massachusetts VIECE►VED
City/Town of
System Pumping Record oC1 0"� 2022
Form 4 TOWN OF N0� pNUUVER
H pVt-1ti
fV' ENT
DEP has provided this form for use by local Boards of Health. Other forms►'�iA�be T 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 - G(V ma C n
key to move your Address
cursor-do not NC) 1 O (/`f )MCA
use the return City/Town State Zip Code
key.
` 2. System Owner: I
Name
hs
Address(if different from location)
City/Town State Zip Code
9 7 F r d?3
Telephone Number
B. Pumping Record
�-a9-tea 1. Date of Pumping Date 2. Quantity Pumped: Gallons �ooU
3. Component: ❑ Cesspool(s) ,Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Fz'No= If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
ZSD
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112 System Pumping Record•Page 1 of 1
1� .