HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 BRIDGES LANE 3/11/2024 y
_ Commonwealth of Massachusetts
City/Town ofrP�a
System Pumping Record
Form 4
11
DEP has provided this form for use by local Boards of Health. Other forms mayee used, but tli , .5'(r
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
key to move your Address
cursor-do not
kuse ey.the return City/Town /J L���!�� lid r Se
Zip Code
—I1 2. System Owner:
Name
Address(if different from location)
City/Town State
Zip Code
90- - 2i0 �
Telephone Number
-B. Pumping Record
10
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ,T Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Y s :N:o:-DIf yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
n
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
M