HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 195 OLYMPIC LANE 4/3/2023 <�N Commonwealth of Massachusetts PE�S'Nr'-p
City/Town of �C11 . 1L L.
Y 1 �� � oti3
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Ot 1 � be used, but the
information must be substantially the same as that provided here. Be a 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, V
use only the tab
key to move your Address
cursor-do-not
use the return
key. City/Town State Zip Code
2. System Owner:
Name
,earn
Address(if different from location)
City/Town State �/i�p(Code
a.l �"l
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
p g Date Gallons
3. Component: ElCesspool(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:
(1;(1 C5
6. System Pumped By: 01\ C i1
1 u
Name Vehicle License Number
Wayne's Drains, Inc.
Company
7. Location where contents were disposed:
View l A U3Q m� U�C1�1
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record• Page 1 of 1
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