HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 245 BOXFORD STREET 4/29/2024 Commonwealth of Massachusetts
City/Town of - C\W\fei 1S 1
J
System Pumping Record yet
Form 4 h 0
DEP has provided this form for use by local Boards of Health,+( tforms may b
ut the
information must be substantially the same as that provided here. Before S om,bcheck with your
local Board of Health to determine the form they use. The System Pum)4' ecord must be Nbmitted to
the local Board of Health or other approving authority within 14 days from the pumping-`Itte-f i)
accordance with 310 CMR 15.351..
A. Facility information
important:when
filling out forms 1. System Location:
on the computer,
use only the tab J l v
key to move your Address 1�\
cursor-do not ��JV'��
use the return �r L"
key. City/Town -
5�8te Zip Code
2. System Owner:
�e,V;
-_� Name
Address(if different from location)
City/Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) [ 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:
G00 6
6. System Pumped By:
_____ (No
Name Vehicle License Number
Wayne's Drains, Inc.
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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