HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 183 VEST WAY 11/14/2023 Commonwealth of Massachusetts
City/Town of � 1 , �� EP�RJ`�Tt Nl
U System Pumping Record ��N
D
Form 4 y�P
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 1 i
key to move your Adddress
cursor-do not I
use the return C'� t'( i
key. CitylTown i
$t5to ---
� 2. SySt m Owner. ZiP Code
IL AP
Name
Address(if different from location)
CRY/I own
State Zip Code
B. Pumping Record Telephone Number
1. Date of Pumping /D Z& 63
'
Date 2. Quantity Pumped: 4
Gallons �—
3. Component: ElCesspool(s) Septic Tank
TTT El 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:
6. System Pumped By:
Name
vehicle umnss Number
Company
7. Location where contents were disposed:
S
Sign of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Dabs
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