HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 95 OLYMPIC LANE 7/31/2023 Commonwealth of Massachusetts pPR�M�N�
City/Town of
w° System Pumping Record SO-
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may 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 (7)
key to move your Address
cursor-do not e }n /�
:.use the return !i /l� �n-
key. Cityrrown Cd
State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State
Zip Code
B. Pumping Record Telephone Num ber
1. Date of PumpingDate 2. Quantity Pumped
Gallons
3. Component: ❑ Cesspool(s) [,Septic Tank ❑ Tight Tank
9 ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned?
❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
N•�ame M C5 vehicle License Number
Company
7. Location where contents were disposed:
Signatur auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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