HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 97 COMMERCE WAY 8/3/2023 Commonwealth of Massachusetts
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System Pumping Record
Form 4
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D EP 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 .f�
filling out forms 1. System Location:
on the computer, IQ CO
use only the tab
key to move your Address
cursor-donot .3 Lmhl
use the return
urn \1 u\
key. City/Town _ - State Zip Code
Q2. System Owner:
Name
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Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 1r
1. Date of Pumping Date Gallons
2. Quantity Pumped:
3. Component: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
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6. System Pumped By:
TIV= MU M
Name U Vehicle License Number
Wayne's Drains, Inc.
Company
7. Location where contents were disp sed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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