HomeMy WebLinkAbout- Septic Pumping Slip - 24 FARNUM STREET 12/5/2022 Commonwealth of Massachusetts
City/Town of o 5 2022
System Pumping Record pEC
ANpovER
Form 4 TOWN OF NpEPA 1� T
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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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System location:
on the computer,
use only the tab q Aa col cou w
key to move your Address
cursor—'do not /
use the return City/Town '�C/ ���l�C
key. State Zip Code
-� 2. System Owner:
Name '
(fir—I' Address(if different from location)
City/Town State Zip Code
�i ?t);- 3 7c� tl c�� 3
Telephone Number
B. Pumping Record
1. Date of Pumping /7
Date/ /_ _ �2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(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:
k
6. System Pumped By:
Name �• Vehicle License Number
C. 1 c' C ZC'
Company
7. Location where contents were disposed:
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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