HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 33 EAST PASTURE CIRCLE 1/2/2024 Commonwealth of Massac , usetts
City/Town of MW1f C G)Le✓-
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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 Loco on:
on the computer, i}, I'� ��`� t J�C ,(J Cl r�
use only the tab "NA
/ J�//� 1
key o move your Address
/f/�/ U.G
cursor- et not �
use the return
key. dytTown State Zip Code
2. System Own r:
r� �v A
Name
Address(if different from location)
City/Town State _._fipCode
Wq
Telephone Number y
B. Pumping Record
1. Date of Pumping Date // 2. Quantity Pumped: Gallons
3. Component: ElCesspool(s) M4 eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): �/ ------- — -
4. Effluent Tee Filter present? ❑ Yes, No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed ition of component pumped:
CA
6. �em Pumped By: �,`01-
If(
�me Vejhicle License Number
p So
Company
7. Location wher ntents were disposed:
Signa ure of a er Date
Signature of mg Facility(or ch facility receipt) Date
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