HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 130 CHRISTIAN WAY 12/9/2024 Commonwealth of Massachusetts
City/Town of
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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 forrn, 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 31OCk4R 15.351 HOUSE: (�roDnt back side rear left(�
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling Out forms 1. System Looatiun�
on the computer.
use only the tab
key»n move your Address
cursor'uonot
MA
*same return
k*y, City/Town =a= Zip Code
2. System Owner:
Name
Address(if different from location)
MA
City/Town State
'fe—lephone Number
B. Pumping Record
I Date of Pumping 2. Quantity Pumped:
Gallons
3. Component: Cesspool(s) Septic Tank 7 Tight Tank Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? [] Yea No If yes, was it cleaned? 7 Yes No
5. Observed condition of component pumped:
6. Gyobam Pumped By:
OoveT|n
um
Name Vehicle License N be
eateson Enterprises, Inc.
Company tion where contents were disposed:
GLS
na u of Hauler
Signature-of ReceivinglFacility(or attach facility receipt) Date
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