HomeMy WebLinkAbout- Septic Pumping Slip - 1635 OSGOOD STREET 1/9/2024 lugCommonwealth of.Massachusetts
City/Town of L cve
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,
use only the tab SV_
key to move your Adder
cursor- not \�use the return Y��c >.Q,!"
Ctty/Town
�I State 2. System Owner A)(':ode
tit cue �
Name
iwno
Address(if dttferent from tocatbn)
"'W I own
State Zip Code
B. Pumping Record Telephone Number
1. Date of Pumping
Date 2• Quantity Pumped:
3. Corn
ponent: ❑ Cesspool(s)❑ Other(describe): El Septic Tank
❑ Tight Tank ❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes ❑ No
If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Sy tern Pumped B
ri
Vehicle Uoense Number
Company —
7. Location where contents were d' sed:
loe
Sign of Hauler
Date _.
int4.doc-11/12
Signature of Recehring Facility(or attach facil
ity receipt) I Date
System Pumping Record•Page 1 of 1
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