HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 286 RALEIGH TAVERN LANE 4/22/2024 Commonwealth of Mass chusetts
Y
Cit /Town of �h AnddL e✓
System Pumping Record
Form 4 APR 2 2 2024
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 lL]2.S / l�i!' ►^ 1 a I gr-r/1 �Cz"� ► l _y V � Y
key to move your Address
cursor-do not /V o r4inyj Ay'er j Ai ,L�`
use the return City/Town State Zip Code
key.
2. System Owner:
n C arc w 1 C 2
Name
Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) VSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Z No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co dition of component pumped:
�CD2
6. System Pumped By: 747,
Name Vehicle License Number
y;I��A.�,-z,,�, �� �PI14* FVT
Company
7. L iation whe contents were disposed:
_ y I kol 2A
Sig ture of ler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record•Page 1 of 1