HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 33 SHERWOOD DRIVE 12/13/2024 Commonwealth � Massachusetts
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System Pumping
Record
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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 eoma as that provided hare. Before using this form, check with your
|OCa| Board of Health to determine the form they use. The System Pumping Record must be submitted Lo
the local Board of Health or other approving authority within 14 days from the pumping dote in
accordance with 310CMR 15,351
2�>back side rear left
A. Facility Information BUILDING: -F��'t back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
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cursor'donot MA 0 11�� S—
uoethe return
key� City[Town State _- Code
2. SysternOwneri
i4A
City/Town State Zip Code
-tWlephone Number
B. Pumping Record
1� Date ofPumping Date 2, Quantity Pumped. Gallons
3. Component: F7 cesspool(s) Septic Tank Tight Tank Grease Trap
[] Other (describe):
4� Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? E] Yes F� No
5. Observed condition of component pumped:
8. System Pumped By',
_gave Tin Mass 1A\95
Nana Vehicle License m
Bate F-Dter ri es |DO
7. pLQation h te te were disposed: