HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 225 CARLTON LANE 12/11/2023 Commonwealth of Massachusetts TMENT
City/Town of , 4 J HEALTH De?P'S
System Pumping RecordForm 4 pEC 11202
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 rJ C 1 { 1
key to move your Address
cursor-do not ^
use the return
key. clty/Towne�-- -- ---- —_
2. Syll em 0Wnec Stet Zip Code
Name
Address(it different from location)
City/I own
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ( 0-a•1-1.3
Date 2. Quantity Pumped:
3. Component: Gallons
❑ Cesspool(s) Septic Tank
❑ Tight Tank ❑ Grease Trap
ElOther(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:
NameVehicle Uoenee�N
Company a
7. Location where contents were disposed:
1 ,
Sign of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date _
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