HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 115 CRICKET LANE 7/10/2023 Commonwealth of Massachuse ..��'
CIty/Town of
S NAP
System Pumping record 10 2a23
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be use
information must be substantially the same as that provided here. Before using this form
local Board of Health to determine the form they use,The System Pumping Record d' but the
the local Board a Health et other approving � check with your
pP 9 authority. must be submitted to
A• �a�alaf� �n��>rrra��A®tau
important:
When rifling out 1_ System Location:
forms on the
computer,use '4
•
only the tab key Address /`
to move.your
cursor-do not !(� A �O �,
use the return City/Town /111,76
key. state
2• System Owner: zip Code
n � Name
rsnn Address lifdifferentfrom location)
Citylrown
State Zip Code
Telephone Number
�. Pumpin_ Record
1. Date of Pumping G� 3--�3 ,
Date 2. Quantity pumped: / D
3. Type of system: Gallons
❑ Cesspool(s) `Septic Tank
❑ Tight Tank
❑ Other{describe}:
4. Effluent Tee Filter present? ❑ Y s ( No ) If yes, was it cleaned?
J Yes No
5. Condition of System:
6. System Pumped By:
Name
Vehicle License Number
IcS s EP -cc
Company
7. Location where,,contents were disposed:
►gnature CwHauler Date
t5form4.doc-06/03
System Pumping Record.Page 1 of t
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