HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 102 LOST POND LANE 6/11/3202 Commonwealth of Massachusetts 617doVer
4 City/Town of45
System Pumping Record
Form 4
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DEP has provided this farm for use by local Boards of Health. Other farms may be use Raft
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. S Stem Location:
on the computer,
use only the tab
__.... . ....__...
key to move your XF
s
cursor-do not
use the return __ _. .... ---___--- --- _-- _ .__.......... _........
._.. --
key. City/Town State Zip Code
2. S ste n, Owner:
rah
Name
.
Address(if different from location)
_ _. ................ .._. .--.... .. ----- ---._--- _ --
City/Town State Zip Code
- .._....-............-----------..__..__..- .._..._--_----
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? ❑ Yes IVa If yes,was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component pumped:
r�
6. System Pumped By:
--_ rc ----- --------. __ _ _ .... - f .......
Name Vehicle Icense
__._......
Number
Company
7. Location wh a antents were disposed:
............ _.. -.... - --- --_.._ ---------------- ------ - -
Sigrfafure of auler Date
_.. _. _ _._.... ----- _.... _. -_--. -.._..
Signature o wing Facility(or ch facility receipt) Date
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