HomeMy WebLinkAboutSeptic Pumping Slip - 126 Pheasant Brook Rd - 11/20/2024 - Septic Pumping Slip - 126 PHEASANT BROOK ROAD 11/20/2024 Commonwealth of Massachusetts
w 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1'. System Location:
on the computer, ff
use only the tab
key to move your Address
cursor-do not /
use the return _ __.__ ._ .. r t .--- 7 1.__. _._ _._.
key. CityCTown State Zip Code
2. System Owner:
air
parr
Address(if different from loomion)
City/Yawn State
m Zip Cade
Telephone Number
B. Pumping Record
1, Date of Pumping __.�_._)_ "
p g Date — _ 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) [❑Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _..____..__..._. _..__.._
4. Effluent Tee Filter present? ❑ res� No , If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped`By:
__.._... ..____... ...._ ._... ..._ _ _..._.. :.__._._..
Name Vehicle License Number
Company
7. Location wherg contents were disposed:
iC°�1 c y ._..___.........- ---. .__._. .-._..... _-..._. _..._-_. — -----..__.. ___... .__.............. . .--- -
Signature of Mar Date
—.__.__._--__ _i____...-_.._......._._ —__..-.-.-._...___.c.--)-- __-. _.......----------
._�__._._ ._._.._.__.-- -.._.__,.__..
Signature of Receiving Facility(or attach facility receipt) Date
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