HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 140 BRIDGES LANE 1/2/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 ,pN
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, lLAo 90 l�9 / 2fy�
use only the tab (� _—
key to move your Address
cursor-do not /vvmr.) ,finclo�-Rr clX(4S
use the return MA
key. City/Town State Zip Code
2. System Owner:
- W(?5-&
Name
nem
Address(if different from location)
City/Town State Zip Code
66(9 - o2LsS
Telephone Number
B. Pumping Record
1. Date of Pumping v' -- 2. Quantity Pumped: t�y
Date Gallons
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 condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
L
Signature of Hau r Date
Signature of Receiving Fa ility(or ach facility receipt) Date
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