HomeMy WebLinkAboutSepticTank - Septic Pumping Slip - 10 OLYMPIC LANE 2/5/2024 Commonwealth of Massachusetts
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System Pumping Record
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Form 4
D EP 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, V l( MP 1 c/
use only the tab �J
key to move your Address
cursor-do not
use the return,
key. City/Town State Zip Codeed,VeC
2. System Owner. fi0 W31
Name
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Address(if different from location) nt
Crtyli own State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping � ( �a
Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(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 co^^ponent pump,-d:
6. System Pumped By:
HV WQJ yn* yt't-"�a1�
Name Vehicle License Number
Wayne's Drains, Inc.
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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