HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 BRUIN HILL ROAD 1/2/2024 Commonwealth of Massachusetts
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System Pumping Record
�M 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. $ tem Location:
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use only the tab VA' 061wi
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use the return Cityrrownn State Zip Code
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2. System Owner:
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Name
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Address(if different from location)
City/Town State r^ 6S-I+p code( q
Telephone Number l(l
B. Pumping Record _
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 03/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
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6. System Pumped By:
Name Vehicle License Number
Company
7. Location where ntents were disposed:
Signature of Ha er Date
Signature of Receiving cili ch facility receipt) Date
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