HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 111 BROOKVIEW DRIVE 4/22/2024 Pa !�arh5
h rc�
Commonwealth of Massachusetts
City/Town of /0: k ki,�kve�' APR 22 2024
System Pumping Record
Form 4
�M
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 I—--L —L bobby-y 1 e
key to move your Address
cursor-do not A1!44, Aod /e r 'AA 01? f-(S
use the return City/Town State Zip Code
key.
2. System Owner:
A i Lha e 1 TL"1 ►a(vA
Name
Address(if different from location)
City/Town State Zip Code
(,I-1 - 9 3g+ — Q :j
Telephone Number
B. Pumping Record
1. Date of Pumping JZuDate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) IR/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes En No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
�CC3d
6. System Pumped By:
Name Vehicle License Number
Company J
7. Location where contents were disposed:
Signature of auler Date
Signature of eceiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record•Page 1 of 1