HomeMy WebLinkAboutSeptic Pumping Slip - 95 Olympic Ln Commonwealth of.Massachusetts
lugCity/Town of
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 • b
Important:When �°��
filling out forms 1. System Location: 4
�02
on the computer,
use only the tab
key to move your Address
cursor-do not .
use the return (� y i
City/Town ._ State
� 2. System Owner
Name
aaa
Address(if different from location)
C w I own State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date -7 c -1 2. Quantity Pumped: �� 0
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
9 ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned?
❑ Yes ❑ No
5. Observed condition of component pumped:
- ` . _ - - • - _ - �. ,.,--sue$. �. �. _
6. tem Pumped By:
19
Na r` &
��aa
Vehicle License Number
Company
7. Locaf n where c tents were disposed:
Sign of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5fomt4.doc-11/12
' System Pumping Record•Page 1 of 1
i