HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 445 BOSTON STREET 10/10/2023 Commonwealth of Massachusetts
'V City/Town of
J.�
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, 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, �3
use only the tab "(AS
key to move your Address
cursor-do notuse
key.there :m - C /rown _ State
Zip Code
2. System Owner:
ld
Name
rw,
Address(if different from location)
City/Town state Zip Code
Telephone Number
B. Pumping Record
in ' 1 �'
� 2�
1. Date of Pum a3
p g Date 2. Quantity Pumped: Gallons
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:
G()0 0
6. System Pumped By:
Name Vehicle License Number
Wayne's Drains, Inc.
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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