HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 496 WINTER STREET 1/2/2024 Commonwealth of Massachusetts
RAMIPMW City/Town of
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, 1 t(�1 . W /1 k-e r 5�,re e-�-
use only the tab _ -- —
key to move your Address
cursor-do not N0(-A-1'N Je r XAA, ��S
use the return City/Town State Zip Code
key.
2. System Owner: ,
�ar� �,e�y �I�ws►�,
1 Name - - -
,� y_a ck
Address(if different from location)
City/Town State Zip Code
aZ 8
Telephone Number
B. Pumping Record
1. Date of Pumping DateGallon2. Quantity Pumped: )COO
3. Component: ❑ Cesspool(s) Veptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — _ -_--_ ---- -------- -
4. Effluent Tee Filter present? ❑ Yes
o If yes,was it cleaned? ❑ Yes ❑ No
5. Observed cpndition of component pumped:
V00
6. System Pumped By:
--
Name , Vehicle License Number
�M044-1 d. C -Wt( Sawi Pk.vrtS�nS 4t�a4"I
Company
7. Location wh contents were disposed:
Signa of uler—) Date
Signature of Rece Facility(or attach facility receipt) Date
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