HomeMy WebLinkAboutSeptic Pumping Slip - Septic Pumping Slip - 7 DUNCAN DRIVE 10/17/2024 Commonwealth of Massachusetts
C ity/Town of
System Pumping Record
7
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 mast 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. --
HOUSE: t
nt back side rear left right
A. Facility Information BUILDING: t back side rear left right
Important:When DI"CtC: under j
filling out forms 1. System Location: 1,
on the computer,
use only the tab {_C-V)
key to move your Address
cursor-do not MA
use the return City/Town' ry State Zip Code
key.
t�Q 2. System Owner.
41 Name
Address(If different from location)
_ MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Component: ❑ Cesspool($) I Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No �I
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tlney Mass 1AA95B Mass 1AD31Z
Name Vehicle License Numb r
sateson Enterprises, Inc.
Company
7. CL& tin where contents were disposed:
GLS0
Signature of Hauler Date
Signature of Receiving Faollity(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record•Page 1 of 1