HomeMy WebLinkAbout- Septic Pumping Slip - 542 SHARPNERS POND ROAD 9/19/2023 Commonwealth of Massachusetts o�PP�� tides
City/Town of
System Pumping Record
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 1. System Location:
forms on the �I r
computer,use � j j h(A yi llp f-S f 6cf
only the tab key Address T to move your
cursor-do not --— ----------- --.._.__.... _-._..-
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address'(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gauons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank g El Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pump d By:
C�� • 1 � to �-�v
Na a Vehicle L�iice^nse Number
Company
7. Locat-Ion where contents were disposed:
4Signare of Hauler Date
Signature of Receiving Facility Date
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