HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 440 BOSTON STREET 1/2/2024 _ Commonwealth of Massachusetts
City/Town of �ILd
System Pumping Record 0-1
� 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, L/(�G 5/011 L
use only the tab ✓T
key to move your Address
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
Name
rerm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
/A5-
/Z3
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 es ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name , Vehicle License Number
Company
7. Location where cq4tents were disposed:
Signat a of Ha I Date
Signature of Re cility(or a facility receipt) Date
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