HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 SPRING HILL ROAD 1/2/2024 Commonwealth of�Mps a Ghusetts
City/Town of
- _ System Pumping Record
Form 4
M
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 p"
cursor-do not ��'(��'/w �.l /viy�c.f�
use the return Cityrfown State Zip Code
key.
2. Sy stem Owner:
Name
aim
Address(if different from location)
City/Town St�z�..i��_ jZi�p Code
? lZ5
Telephone Number
B. Pumping Record
1. Date of Pumping Date Quantity Pumped: Gallonsue
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. Obsgrved conditi n of component pumped:
6. S77P?M
:
(�% Ord tL,' i( Zed)
Name ' e License Number
,� 6 al--d 'Sb4 aaN4WehicI
Company
7. Location where ents were disposed:
Signature of Haul r Date
Signature of Rec ' acility(or attach f cility receipt) Date
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