HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 215 GRANVILLE LANE 12/18/2024 Commonwelalth of Massachusetts
$ City/Town of
wn 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,
use only the tab ......
cursor
to move our Address -
cursar-do not --
use the return __.._... . _.. 4Y--- ' ` { ?C d ....... . —.._. ... _.key. City/Town State Zip Code
VQ- 2. System Owner: T"O
Name
reeswn
Address(if different from loca�fion) ® ``
City/Town State
- Zip
. Cade
71?-
Telephone Number
B. Pumping Record
1. Date of Pumping Date-- — 2. Quantity Pumped: Gallons _
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _.----------- __. _..__.._ _...._.
4. Effluent Tee Filter present? No❑ Y( s If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of c ponent pumped:
6. System Pumped`By:
_..... .. ..........
Name Vehicle License Number
Company
7. Location w ere contents were disposed:
° .._.._....... _.._. ._..
_ __.,......Signature of Har _------
_ ..0 ate
Signature of Receiving Facility(or attach facility receipt) Date
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