HomeMy WebLinkAboutSeptic Pumping Slip - 1296 Osgood St - 10/03/2024 - Septic Pumping Slip - 1296 OSGOOD STREET 10/3/2024 Commonwealth of Massachusetts
3 City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms maybe 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1 System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the returns
IV67 State
key. Zip Code
2. System Owner:
Name
(elm
Address(if different from locat�ion) ---
City/Town State Zip Code
Telephone Number fP
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: LEV—
Date - Gallons
3. Component: El Cesspool(s) PlSeptic Tank n Tight Tank n Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? R Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number A.
Company
7. Location whey p contents were disposed:
Signature of Date
Signature of Receiving Facility(or attach facility receipt) Date