HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 83 CAMPBELL ROAD 1/2/2024 Commonwealth of Massachusetts
City/Town of A&34., .0ovc-C . �TaN
System Pumping Record so
w 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
key to move your Address
cursor-do not AA2r oA ,t�+ _�,
�'�"
use the return City/Town ^ �r
key. State Zip Code
2. System Owner:
Name
nam
Address(if different from location)
City/Town State Zip Code
a`f g 3� 3 — Z 5z3
Telephone Number
B. Pumping Record I
1. Date of Pumping !I/W Z 2. Quantity Pumped: O=�
Date Gallons
3. Component: ❑ Cesspool(s) V Septic 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:
CwDd -
6. System Pumped By:
q 1�C�
- � --
Name Vehicle License Number
TiM I�� A •C�i���1_� PI r✓+.^'►5�n y � �►f�-I'n�
Company
7. Location where contents were disposed:
L
Signature of Ha ler Date
Signature of Receive 'lity 3attachty receipt) Date
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