HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 92 REA STREET 7/18/2024 Commonwealth of Massachusetts Town
City/Town of
System Pumping Record 4 2025
Form 4
. earth
DEP has provided this form for use by local Boards of Health.Other forms m th
information must be substantially the same as that provided here. Before using this for with your
local Board of Health to determine the farm 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 farms 1. System Location:
on the computer,
use only the tab _ .. _....... ,. ..
key to move your Address
cursor-do not
use the return ----. __
key. CitylTown State Zip Code
2. Sy tem Owner:
t
-- Name
Address(if different from location)
City/Town State C _jp Code w
Telephone Number
B. Pumping Record
1. Date of Pumping De 2. Quantity Pumped: Gallons
. Component: ® Cesspool( ) Septic Tank ❑ Tight Tank Grease Trap
❑ Other(describe).
4. Effluent Tee Filter present? ® Yes No If yes, was it cleaned? [ Yes No
5. Observed con `tion of component pumped:
s Pumped By:6. � �
Name Vehicle License Number
Company
7. t ocation wh ontents were disposed:
Signattife of uler Date
Signature of l2ec lity(or attach facility receipt) Date
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