HomeMy WebLinkAboutSeptic tank - Septic Pumping Slip - 17 CROSSBOW LANE 1/2/2024 TO
Commonwealth of Massachusetts LPN
City/Town of �� o
` System Pumping Record
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 Loff��tiOn:
on the computer, ll Crvs$ bb pt,'�
use only the tab --
key to move your Address
cursor- not n 1,v1-.Yh ��p
use the retet not
key. City/Town State Zip Code
2. Syst�caner:
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Name
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Address(if different from location)
City/Town State Zip Code
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Telephone Number
B. Pumping Record /
1. Date of Pumping Date ✓ 2. Quantity Pumped: Gallo/sz)0
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - —
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condi ion of component pumped:
�%�
6. SystemPumped By:
Gil zrd LVc_0 a/ -7d
Name Vehicle License Number
Company
7. Location where is were disposed:
Signature auler Date
Signature of Re cility(or attach facility receipt) Date
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