HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 ABBOTT STREET 1/2/2024 Commonwealth of Mass chusetts
W .City/Town oftitk
System Pumping Record �aN
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 forms 1. System Location:
on the computer, , L
use only the tab o 't'T 'S-k�
key to move your Add u�
cursor-do not 6l6'L—
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: 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:
6. System�rC Pumped By:
�(
ame , V hide License Number
c�� Ol Mtn bi�i;E �lv f
Company
7. Loca ion wh r contents were disposed:
Sign i of a ler Date
Signature of i 'ng Facility(or ch facility receipt) Date
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