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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 CAMPBELL ROAD 1/2/2024 Commonwealth of Massachusetts City/Town of khor-w A n� System Pumping Record 10�� 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, O use only the tab `-t, L, l key to move your Address cursor-do not /tJpr- -V\ MA use the return key. City/Town State Zip Code 2. System Owner: �a i-ftier�'r,,e 1�c�G11e�� �I Name �m Address(if different from location) City/Town State Zip Code q7 q Telephone Number B. Pumping Record ff r 1. Date of Pumping Date 2. Quantity Pumped: gallons 3. Component: ❑ Cesspool(s) Ly 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: ( 9v©J, 6. System Pumped By: ( 7 Name Vehicle License Number heel' Company .J 7. Location where tents were disposed: CAL S p Signatur of H er Date Signature of Rec g Facility(o ach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1