HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 190 GRANVILLE LANE 5/4/2023 Commonwealth of Massachusetts
City/Town of
�i �) System Pumping Record 2023
^ ,/ Form 4 �P� 4 ovER
F NOA'CHR MEND
DEP has provided this form.for use by local Boards of Health. Other formsN( aul the
information must be substantially the same as that provided here. Before usi is 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 15.35.1.
A, Facility Information
Important:When _^
filling out forms 1 Sgstem Location:
on the computer, /
use only the tab ` ��) (, /Gc a I
key to move your Address
cursor,do not /l
use the return �ity/Town ld A V d Lt
key. State Zip Code
2. System Owner:
I�
Name
Address(if different from location)
City/Town State Zip C ode
9 733
Telephone Number
Be Pumping Record
1. Date of Pumping Date/ I 3 2• Quantity Pumped: /000
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes G�r No- If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped.-
Co ri j i +- ,
6. System Pumped By:
Name Vehicle License Number
Company r
7. Location where contents were disposed:
HG� ye'-
r
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
`6
M�