HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 22 TIFFANY LANE 1/2/2025 �^
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System Pumping Record 72025
Form 4
Health
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OEP has provided this form for use by local Boards of Health, Other."rjm9 ' —~ ° but the
information must be substantially the some as that provided here. Before using this form, check with your
|oce| Board Of Health to determine the form they use, The System Pumping Record must be submitted to
the local Board of Health Vr other approving authority within 14 days from the pumping date in
accordance with 310CK8R 15,351 HOUSE: front backy,, side rear, right
A. Facility information BUILDING: front back side rear left ngli�
Important:When DECK: under
Nlingout forms 1 System L
on the computer, r
use only the tab
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ty/Town State Zip Code
2, S
am
Address(if different from location)
MA
City/Town
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped, Gallons
3. Component: Cesspoo](s) Septic Tank Tight Tank Grease Trap
4. Effluent Tee Filter present? [] Yee No >f yes, was iLcleaned? Yea No
5, Observed conditio f component pumped.
8, System PgmpedBy:
DmveT|n
Name \7e—hlcle License Nu
eateson E te . Inc.
Company
7.