HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 CARLTON LANE 1/9/2024 Commonwealth of MassachusettskVj ��C�G✓
City/Town of t' �
System Pumping Record �ti�v �tioti
Form 4 Yl<r~ 110.
DEP has provided this form for use by local Boards of Health. Other forms ma
information must be substantially the same as that provided here. Before usin y be used, but the
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 g this form, check with your
accordance with 310 CMR 15.351. pumping date in
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your qdd Q l —
cursor-do not
use the return olr own
w
2. System Owner --
�(qv
st8te Zip Code
Name '
Address(if different from location)
Citylrown
State Zip Code
B. Pumping Record Te1�`1O1e"umber
1. Date of Pumping �� 4);
Date 2. Quantity Pumped:
3. Component: ❑ C Gallons
esspool(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 condition of component pumped:
6. System Pumped By:
Name � 5 -,Ile
Vehk�e License Number
Corn any
7. Location where counts war disposed:
Sign of Hauler —
- /-
Date
Signature of Receiving Facility(or attach facility receipt) Date
I
rm4.doc•11/12 i
System Pumping Record•Page 1 of 1
i
�_ _
. ....
.. - � ___
-- ---
d �-
., ..
:t
._._ __._ -a1a- • ....
7y.,_- _ __ _-_-.v-._ .J_ - _... __ __�._. __ __ - _-__. _ .� _. _�. _.
:.3