HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 SUGARCANE LANE 8/2/2023 Commonwealth of Massachusetts
City/Town of
System PUMPing Record HE ���atitio2
Form 4
DEP has provided this form far use by local Boards of Health. Other forms may be used
information must be substantially the same as that provided here. Before usingthis ' but the
local Board of Health to determine the form they use. The System Pumping Record must b
the local Board of Health or other approvin form, check with your
g authority. a submitted to
�. �acil�ty In�g�rna�i®�a
Important;
When filling out forms on the 1. System Location:
computer,use
only the tab key Address L� S' C I
to move.your
cursor-do not
use the return Clty/Town : . VV1l•�'
key. ~' state
2• System Owner: ZIP Code
Name ere jT
Address(IfQ.R.
dlfferentfrom locatlon)
Clly,Town
state ZIP Code
77 /— 3o6F-
Telephone Number
'E• B lumping Rec®rd
1. Date of Pumping -7- 20 '� 3 ,
Date 2. Quantity Pumped: �J GG
3. Type of system: Gallons
❑ Cesspool(s) OSeptic Tank ElTight Tank
❑ Other(describe):
4. Effluent Tee Fitter present? ❑ Y rNq If yes, was it cleaned?
yes No
5. Condition of System: a,
6. System Pumped By:
Name
Company Q S 5e�4r Vehicle License Number
7. Location where c ntents were disposed:
l
4,
ignature ovmauier Data
t5form4.doc•06/03
system Pumping Record•Page 1 of 1
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