HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 GILMAN LANE 4/22/2024 Commonwealth of Massachusetts
City/Town of Ardc>xv-
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, � `J 0 t I M
use only the tab (�
key to move your Idoress
cursor-do not Nof4h ArvL,e e, !"vlA j Q(S-
use the return Citylrown State Zip Code
key.
2. SystK
Owner:
oc
Name
germ
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date L 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) UV 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 component pumped:
(±Vd
6. System Pumped By:
5er nd V^1Q1 -
Name Vehicle License Number
-r1m04N A. j
Company
7. Location where contents were disposed:
Si nature Hauler Date
Signature of g Facility(or attach facility receipt) Date
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