HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 53 WHITE BIRCH LANE 1/2/2024 Commonwealth of Massachusetts
City/Town of ki66 k
S stem Pumping Record
Y 9
� 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:
on the computer, -�5-3 1 , �11i-*;11 i,�
use only the tab W (�/l
key to move your Address I
cursor-do not
use the return City/Town state Zap Code
key.
2. System Owner:
Name
nbn
Address(if different from location)
City/Town State Zip Code
Teleph ne Number
B. Pumping Record
SJQ ) 3 �3
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - - - --
4. Effluent Tee Filter present?.XYes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed of component pumped:
6. System Pumped By:
�icrernt G ra w� 1 Z
Name Vehicle License Number
(91 t � n Y�LItibl
Company
7. Location where c ents were disposed:
Signatur4lof Haule Date
Signature of Receivin acility(or a faality receipt) Date
i
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