HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 600 FOSTER STREET 1/2/2024 Commonwealth of Massachustt
City/Town of AOCM
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, (000 A/
use only the tab (� kC l
key to move your Address
cursor-do not �/1�/IV1 TM,VnV1AYI, �f�( (XJ v�J
use the return C ti y/Town State Zip Code
key.
2. System Owner:
Name
�� wain
A res (if di rent from location) AA
City/Town State Zip Code
s�-6 -��2'
Telephone Number
B. Pumping Record
� P�)
1. Date of Pumping Date J 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) U,19'eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -� -- -----
4. Effluent Tee Filter present? ❑ Yes,rJ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Warne Vehicle License Number
VNCY\%Y�A (oi ;� ".Sint I�IwHG��I -IP24111
Company
7. Location where contents were disposed:
l.=J�
Signat of H u r Date
Signature of Re a '' or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record•Page 1 of 1