HomeMy WebLinkAboutSeptic Pumping Slip - 2024-07-03 - Septic Pumping Slip - 53 WHITE BIRCH LANE 7/3/2024 To Wn
Commonwealth of Massachusetts ofIVOrth
ndoV r
City/Town ofFEB 4 025
System Pumping Record
Form 4 lt
DEP has provided this form for use by local Boards of Health.Other forms may be used, butt
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 316 CM 15.351.
A. Facility Information
Important:when
filling out forms 1. System Location:
on the computer, Y
use only the tab
key to move your Address
cursor-do not f
use the return — --. - ------ -- ... — - —— -- --- —
key. City/Town State Zip Code
2. System Owner:
FI_. .__.._ .. _........
— Name
_ -- - _ _ ._.... _ _.....
Address(if different from location)
_...... ------------------------- - ------- .......-_. ................ — — —.
City/Town State Zip
Code
x.
Telephone Number
B. Pumping Record
1. Date of Pumping . ._._..-_..___..._.._._.._ 2. Quantity Pumped -- ------ ---
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Obs
erved c dition of component pumped:
6. System Pumped By:
- - rc -- --- --- .................
),Ime Vehicle license Number
Company
7. Location wher c ntents were disposed:
C
---- . ---............... , --......._...__.. -----—.___-----.... -- — —.-..._......_.. ------- .—
Signatum of uler Date
Signature of g Facil" or attach facility receipt) Date
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