HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 210 FARNUM STREET 1/2/2024 Commonwealth of Massachusetts
City/Town of 4� ,/�r��/ �130
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, 216 rac r)uA9
use only the tab
key to move your Address
cursor-do not �/fJ� A170(061e✓-
use the return
key. City/Town State Zip Code
2. System Owner:
ye// SAG beh
Name
— —------——--- -----------------------
Address(if different from location)
City/Town State Zip Code
W7,83
� 7~83
Telephone Number
B. Pumping Record
1. Date of Pumping ?�17�23 2. Quantity Pumped: y
Date Gallons
3. Component: ❑ Cesspool(s) ErSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --- — -- -- ----- — -
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed co dition of component pumped:
6. System Pumped By:
Name Vehicle License Number
I-rol1krf A Gi
Company
7. Location where contqMs were disposed:
Signature o Haul r Date
Signature of Rece ' ty(or attach fac' receipt) Date
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