HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 REA STREET 1/2/2024 Commonwealth of JVIassac� etts
City/Town of �t �pti4
T� I 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 1
key to move your Addr s �t
cursor-do not /( �� vl•L'� Ii--4use the return key. City/Town State Zip Code
2. System Owner:
�' -
Name
Warn
Address(if different from location)
City/Town State Zip Code
33 q— Z 2Z-- (o r--y8`
Telephone Number
B. Pumping Record g-1.7 , l�
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) epbc 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:
�bu U
6. stem Pumped By:
Name ,Vehicle License Number
-I'i rv.\0-4� (a rc( �.I�Iwr► !�-�� ,?j
Company
7. Location where c ents were disposed:
L D
Signature of Hauler Date
Signature of Re eivin cility ch facility receipt) Date
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