HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 75 FOREST STREET 12/18/2024 Commonwe'alth of Massachusetts
City/Town of
wro 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 71-
—----------
key to move your Address
cursor-do not
use the return
key. City/Town State --------- Z'
2. System Owner: INV$%
VQ W
D e v &\
Name
---------------- --l-.............
Address(if different from o-c-iii-o*h')- ------
le�l
de
-feilep;h�on'e-Num 6e- -------------
B. Pumping Record
- Y
1. Date of Pumpingante 2. Quantity Pumped.
Gallons
"
3. Component: F-1 Cesspool(s)(-,17Septic Tan ) F-1 Tight Tank F Grease Trap
El Other(describe): ----........------------------ -------
4. Effluent Tee Filter present? F Y(!-S--p--N0 If yes, was it cleaned? ❑ Yes El No
5. Observed condition of component pumped:
6. System PumpedBy:
Name Vehicle License Number
Company
7. Location whey p contents were disposed:
------------------------- ------------------- ----------
.................... - -----
Signature of Hair Date
Signature of Receiving Facility(or attach facility receipt) Date
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