HomeMy WebLinkAboutSeptic Pumping Slip - 10/3/2024 - Septic Pumping Slip - 25 ENGLISH CIRCLE 10/3/2024 Commonwealt of Massachusetts rown of
City/Town of ( ; or
µ System Pumping Record ndo yer
Form 4 025
DEP has provided this form for use by local wards of Health. Other used, but the
information must be substantially the same as that provided here, Before usl a r , check rwiith your
local Board of Health to determine the form they use. The System Pumping Record m t itted to
the local Board of Health or other approving authority within 14 days from the pumping date i
accordance with 310 CMR 15. 51.
A. Facility Information
Important:when
filling out farms 1. System Location:
on the computer,
use only the tab ! _ _ _.......
key to move your Addr ss d��,e
Ccursor-do not - J +5
use the return
key. City/Town State Zip Code
2. System Owner: en
ame
Address(if different from location)
City/Town State Zip Code
Teiaphane Number
B. Pumping Record
f / -
1. Date of Pumping 2. Quantity Pumped: .
pate Gallons
3. Component: Cesspool(s) eSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _. _ _ ....
4. Effluent Tee Filter present? ❑ Yes,Z No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi of component pumped:
6. System Pumped By:
.
Vehicle License Number
., r
Comp ny f/°
7. Location w re ontents were disposed:
r
iatur Sig t� of _.._ _........._ --._ -._.. __._.... .. _._.... .......___ ___._...... ._. - _......_. ._..
Hauler _ � pate
Signature f Re 'mg PacAlity(or attach facility receipt) pate
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