HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 JERAD PLACE 1/2/2024 Commonwealth of Massachusetts
City/Town of I(Ay7- AI �—
o System Pumping Record Ny �TO4
µ 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, r26C P l&C
use only the tab
key to move your Address
cursor-do not A 7V\ 0
use the return Cityrrown State Zip Code
key.
2. System Owner:
Name ----
aw
Address(if different from location)
City/Town - State 76 I — -ram gkq ZIP Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ YeSNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con ition of component pumped:
LQn
s. System m ey.
Name Vehicle License Number
Company
7. Location where 46ntents were disposed:
Signature f Haul Date
Signature ceivi Facll' attach facility receipt) Date
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