HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 88 HAY MEADOW ROAD 1/2/2024 � Commonwealth of Massachusetts $txl
51___- City/Town of f114'V"
System Pumping Record
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: I
on the computer, Q-J6
use only the tab CC��
key to move your 77!-h
cursor-do not ( r 4 -
use the return City/Town State Zip Code
key.
2. System Owner:
lA, c,0�el �;DUL1
Name
was
Address(if different from location)
CitylTown State t-7—� i Zi
C &q
ry [ �'
Telephone Number
B. Pumping Record
1. Date of Pumping Date "7 l 2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) 04-19eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present,ZYes ❑ No If yes,was it cleaned? Yes ❑ No
5. Observed con ion of component pumped: /
6. System Pumped By:
�Na-m�e� , � Vehicle ' Number��
dorfipany
7. Loc tion whe contents were disposed:
Signature of au er Date
Signature of Recei ' Faality(or facility receipt) Date
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