HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 CRICKET LANE 3/11/2024 Commonwealth of Massachusetts
City/Town of p,�d®SEC
System Pumping Record �403
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms Azay 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 y /Ro C 'C�!' /n
-key to move your Address
cursor_et not �L,� A � /C
use the return
key. City/Town State Zip Code
2. System Owner:
C k4_
Name
rain.
Address(if different from location)
City/Town State _ Zip Code
�t6/- �jSa _ p/ 7/
Telephone Number
B. Pumping Record c�
1. Date of Pumping Date / 2. Quantity Pumped: Gans
SZ0
ons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ es f DNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
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6. System Pumped By:
Name Vehicle License Number
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Company
7. Locati/tion where
contents were disposed:
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Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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