HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 160 CARLTON LANE 4/22/2024 Commonwealth of Massachusetts
r.
City/Town of AL Lk. *(100-6c
m = System Pumping Record
� 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 Locatio
on the computer, I �0 ��� L3t/ e
use only the tab 1 L.7 � � V
key to move your Address -
cursor-do not /� lDC11n ArCbUer
use the return City/Town ► 1 State Zip Code
)AA.
key.
2. System Owner:
vs—w-A
Name —
nrm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: l �Uv
Date �,/ Gallons
3. Component: ❑ Cesspool(s) [!Q Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - ---------- -- -
4. Effluent Tee Filter present? ❑ Yes �- /No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con ition of component pumped:
��19
6. System Pumped By:
j<f C�Iand 1�U�a1 `� 0
.__,Name Vehicle License Number
I(� �• ' 1�1'1
Company a
7. Location where contents were disposed:
S' t of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1