HomeMy WebLinkAboutSeptic Pumping Slip Commonwealth of.Massachusetts
City/Town of „r4„e,�
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
Important:When ���
filling out forms 1. System Location: 2 C 2024
on the computer, /3
use only the tab I�5 �� ,,M _L� 9 A
key to move your Mures
cursor-do not j "'""- •. , L ` .. -„,
use the return �' ex • c` Y �,. `i
y key, City/t'own Y
. - - 2. System Owner: _ - - �e . - --- - - - state , , zip Code
Name
aas
Address(if different from location)
City/I own State
• Zip Code
T elephone Number
B. Pumping Record
1. Date of Pumping --`—i- � aL 2. Quantity Pumped: J
Date 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:
6. tem Pumped By:
Ci LD(�av�
Na a vehicle license Number
Q,1�1
Company
7. Locat n where tents were disposed:
Sign of Hauler
I Date
Signature of Receiving Facility(or attach facility receipt) I Date
t5formCdoca 11/12
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