HomeMy WebLinkAboutSeptic Pumping Slip - 204 Mill Rd Commonwealth of Massachusetts
City/Town of L,. ,��
_ system Pumping Record
Form 4
DEP has provided this form for use by local Boards of Hetpalf,'j. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
mitt
local Board of Health to determine the form they use. The System Pumping Record must be sub ed 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
key to move you, Address
cursor-do not
use the return 9• �.�^�
key, City/Town •� �� r 1 ' `-i
R - - . Zip Code-- - _ - " _- --- Stag
2. Syster n Owner: _ T
Nam-- .�e�;
Address(if different from location)
Clty/Town
Zep Code --
B:humping�A6Coxd ----
1. Date of Pumping ~ Date 2. Quantity Pumped:
Gallons
3. 'Component: y' ❑ 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. j8e Pimp By:
Vehicle License Number
y
7. Locatio where ntents were disposed:
;'".`._.Sign of auler-.___—— Date
i
Signature of Receiving Facility(or attach facility receipt) Date - _. _.-__ ` •
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