HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 BRIDGES LANE 1/2/2024 Commonwealth of M ss chu�setts
City/Town of y7G�G
System Pumping Record
Form 4 LPN
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, ' �
use only the tab
key to move your Address
cursor-do not
use the return Citytyffown State Zip Code
key.
2. Systeip Own r:
Name -
nenr
Address(if different from location)
CitylTown staI& yZip Code
l eG� `.G o
Telephone Number
B. Pumping Record
A 2 �
1. Date of Pumping 2. Quantity Pumped: /
Date 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 coonnrion of component pumped:
( xu ' - -
6. System Pumped
�y.
r hicle License Number
WC
Company
7. Location where c tents were disposed:
L
Signat of Held Date
Signature of R Fa ' '7�0 facility receipt) Date
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