HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 520 SHARPNERS POND ROAD 1/2/2024 Commonwealth of Massachusetts
1 City/Town of -4!�
System Pumping Record IN
p g
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, C 2 Q C v) r-`'n e c
use only the tab J J��G` J _
key to move your Address A Ir^�A _
cursor-do not Na�h ✓fi ycx- /AA (g45
use the return key. CitylTown State Zip Code
2. System Owner:
Name
nYn
Address(if different from location)
City/Town State��' S�� ��ip�de
Telephone Number U''1
B. Pumping Record
CM
1. Date of Pumping D!te(�2� 2. Quantity Pumped: Gall2
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ----- - --___------
4. Effluent Tee Filter present? ❑ YesZNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
( Oo d
6. System Pumped By:
ferny �4 C - —- W 60q -7
�Name 1 7y ^ �I � Vehicle License Number
Company
7. Location where c9ptents were disposed:
Signafdre of H er Date
Signature of Rec Facili ,.(of attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1