HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 JAY ROAD 4/3/2023 _ Commonwealth of Massachusetts
City/Town of
1pti3
System Pumping Record
Form 4 �� �p�10
DEP has provided this form for use by local Boards of Health. Other forms" y 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 �U rl OY �Y
use the return
key. City/Town State Zip Code
2. System Owner:
r�
Name 144
Address(if different from location)
City/Town State Zip Cod
Telephone Number
B. Pumping Record
1. Date of Pumping 3 �6 Date Gallons
3 2 Quantity Pumped: O d
3. Component: ❑ Cesspool(s) .Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ZNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of/component pumped:
6. System Pumped By:
Name ti• Vehicle License Number
Company
7. Location where contents
/were disposed:
/`1G
Signature of Hauer 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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