HomeMy WebLinkAbout- Septic Pumping Slip - 165 CARLTON LANE 7/22/2024 IL lct 001el
Commonwnlaalth of Massachusetts
City/Town fjj� �� �A"J"
w System Pumping Recor ��t �21oti4
Form 4 gh�
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 l n �— Q( I n
key to move your Address
cursor-do not J1 ,U r &dG AA;Q
key the return Cityrrown Sta-- te 1 ' Zip Code
Y
2. System Owner:
ratr
Name
rsxrn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping —5J -Y--- 2. Quantity Pumped:
Date 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:
6. SyemPumped By:
Name MM Vehicle License Number
&�rr
Company
7. Location where contents were disposed:
Cz L
Sign of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112
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