HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 226 ABBOTT STREET 1/2/2024 Commonwealth of Massachusetts
�1 City/Town of
System Pumping Record �'LOti
Form 4N'
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, ZL(. Auob+
use only the tab
key to move your Addj ./� /� , e/
cursor-do not !/v�/�l ' ✓Cl j l�`'C�' , � 01 �s
use the return City/Town State Zip Code
key.
2. System Ovin�� l t \� C/Y t
t
Name
nrs
Address(if different from location)
City/Town State ZIP
p Code
� �-
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 9-9eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — -- - —
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condit' n of component pumped:
fog
6. �em Pumped By: ,
Name tt/ehicl License Number
Company
7. Location where co tents were disposed:
-6-g-natuprof Ha a Date
Signature of R aality(or atta cility receipt) Date
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