HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 REA STREET 1/2/2024 Commonwealth of Massachusetts
City/Town of �C2►�d-h N�� �N- �1Ati
System Pumping Record
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,
use only the tab
key to move your Address
cursor-do not ^ / /j� 4l A � ,(Alt-+
key.
use the return Ciittyrro^wn State— Zip Code
2. System Owner:
Name -
nem
Address(if different from location)
City/Town State p Code
a-7�^ g"l3-j a ts-
Telephone Number
B. Pumping Record
1. Date of Pumping Date �/ 2. Quantity Pumped: Gallons
3. Component: Ell�Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Ye No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
\7)b� --
6. System Pumped By:
Name Vehicle License Number
-T,MQ4141.G,hr�� �n QIIM�►M�V A:�O ^"1
Company
7. Location where, is were disposed:
l.�
Signatur Date
Signature of Rec 'vin Fac'' (or attach!cif receipt) Date
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