HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 FOSTER STREET 4/8/2024 Commonwealth of Massachusetts
�! City/Town of l
System Pumping Record ApR o g 2024
w .,., 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, v l
use only the tab
key to move your Address
cursor-do not ✓1
use the return CfCi V(—
key. City/Town State
Zip Code
2. System Owner:
!•Name A'�+
Address(if different from location)
City/Town State Zip Code
27� - SZJti - 33��
Telephone Number ,
,�. Pumping Record
1. Date of Pumping Date 2.2 y 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspoo Septic Ta k ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter Ares (!? Y ❑ No If yes, was it cleane ?� Ye ❑ No
5. Observed condition of component_pumpgd:
cc) �i �`+ 6 ►�
6. System Pumped By:
Name / Vehicle License Number
Company
7. Location wher contents were disposed:
F
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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