HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 DUNCAN DRIVE 1/2/2024 Commonwealth of' Massachuset'ts
C'ty/Town of lVot
System Pumping Record
Form 4
DES"' has provided this form for use by local Boards of Health. Other forms may be used,, but the
for must be substantially the same as that,providied�, her�e. Before using this form, check with dour
local Board of Health to determine the for 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 inn
accordance with 3101 CIVIR 15.3511
A. Facility Information
Important:Whien
filling out forms 1. System Location-.
on the computer,, "'NO' V Dn
use only the to "Q'............. .......... ........ ................ .......
key,to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. Systern Owner-
--------------
Name
-----------
Address if different from location)
............
City/Town, ........ State Zip Code
Telephone Number
B, Pumpling Record
IIA I(le
DIiate of Pumping Date 2. Quantity Pumped: Giallons
3. Component." El Cesspool�(s,) VSeptic Tank El Tight Tank [:1 Grease Trap,
[:] Other(describe):
4. Effluent Tee Filter present.? El Yes !0 If yes,was it cleaned? El Yes
5. Observed condition of component pumpedl.-
...........
6. System Pumped By.-
............
Name Vehicle License Number
Company
7. Location hey tints were di,si pose
d'o.
Signiat e oif Ha r Date
..........
Signature of R gi Facility(or,attach cility receipt) Date
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