HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 BEECHWOOD DRIVE 6/5/2023 Commonwealth of Massachusetts ENS
City/Town of \AID- �M
System Pumping Record HAP`- O52o'�
Form 4 ►
DEP has provided this form for use by local Boards of Health. Other forms may be used b
information must be substantially the same as that provided here. Before using this form, check with
local Board of Health to determine the form they use. The System Pumping Record of the
the local Board of Health or other approving authority. your
must be submitted to
A. Fac11, y Infonnatlon
important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address v C
to move your
cursor-do not i1O'�'
use the return iry� own --
key. state Zip Code 2. System Owner:
c��f Name S
�I Address(if dffferen tfnm IocaUon)
City/Town
State Zip Code
Telephone Number
I�. Pumping record
1. Date of Pumping S 13 - 3 O
Date 2. Quantity Pumped:
3. Type of system: ❑ Cesspool( Gallons❑ Septic Tan
❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present ❑ Yes No If yes,was it cleaned?
7Y�e ❑ No
5. Condition of System: a.
6. System Pumped By:
Name
S
Vehicle License Number
S C'a�r C
Company
7. Location where contents were disposed:
j�-S
C�'O�1P
Signature of Hauler Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 1
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