HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 93 SUGARCANE LANE 1/2/2024 Commonwealth of Massachusetts
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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, ar-�
use only the tab -q3 _ _-
key to move your Address
cursor-do not NX44i ,A.ncLoLe r
use the return City/Town State Zip Code
key.
2. System Owner:
ame
nem
Address(if different from location)
City/Town State Zip Code
�IQR DgS't7
Telebffbne Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons v
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
d condition of component pumped:
&00 \
6. System Pumped By:
W le6 l-1 C�
Name Vehicle License Number
L� (,r ar,cf ; Sail Pblw►.bi�t ? leaf,
Company
7. Location where intents were disposed:
Signa jaul Date
Signat2—(i&or"attach facility receipt) Date
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