HomeMy WebLinkAboutSeptic Pumping Slip - 76 Olympic Lane - Septic Pumping Slip - 76 OLYMPIC LANE 9/25/2024 Commonwealth of Massachusetts
z City/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 CM R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ()e" Vh f-3)
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date — Galin
3. Component: n Cesspool(s) /Lj Septic Tank n Tight Tank n Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? [] 'es' Na If yes, was it cleaned? n Yes E] No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
t (0- --z e -C
Company
7. Location where contents were disposed:
z
6 eo
Signature of Hal6ler Date
Signature of Receiving Facility(or attach facility receipt) Date