HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 743 WINTER STREET 1/2/2024 1:\1 Commonwealth of Massachusetts �'L xN
City/Town of "I LPN
System Pumping Record
r` 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, — /I 5)�
use only the tab 761
key to move your Address �(..
cursor-do not vV'~✓ 1 AAd"✓ Ql&u S_
use the return City/Town State Zip Code
key.
2. System Owner:
C h 1 /12 'z�2►�►���
Name -- --
a�s
Address(if different from location)
City/Town State Zip Codg Z
S—
Telephone Number
B. Pumping Record � 2 L&�:x-)
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 con ition of component pumped:
Od
6. System Pumped By:
Name r/n. Vehigde License Number
&'ferj? Svn
Company
7. Location where cog a is were disposed:
Signature df Haul r Date
Signature of R cility(or a facility receipt) Date
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