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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 283 CAMPBELL ROAD 10/4/2023 IL Commonwealth of Massachusetts W City/Town of System Pumping Record Form 4 M 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, C���{.�Q (J use only the tab �'J J key to move your �Ad:dress n cursor-do not / r MA use the return Cit /Tow — - key. y State Zip Code f� 2. System Ow r: Same P Name --- ,stun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record n 1. Date of Pumping - --- )6 © y 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 V No If yes, was it cleaned? ❑ Yes "5'No 5. Observed condition``of component pumped: `�- All of this estimated inforrOtion is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. S tem Pumped By: Name Vehicle License Number Company 7. Location where contents were disposed: ,&# art�iving F��a Ti So. Mill St., Bradford, MA 01835_ See above C' +"' -�•�• Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1