HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 292 CANDLESTICK ROAD 6/6/2024 Town Of
Commonwealth of Massachusetts leer
City/Town of
System Pumping Record ow
u
Form 4 el ,
DEP has provided this form for use by local Boards of Health. Other forms may be use
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 _ __
key to move your Address
cursor-do not "
use the return — �- ---.' __..._ _ -- -----
key. City/Town State Zip Code
2. System Owner:
Name
i
Address(if different from location)
-__ _ ..._..__... ___ ...... ._.....__._ _.._----,. _ _..._.._ .__._.__ _
City/Town State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped: - � —
Date Gallons
3. Component: ® Cesspool(s) Septic Tank ® Tight Tank n Grease Trap
® Other(describe):
4. Effluent Tee Filter present?,eyes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
cx 6. stem Pumped By:
Name Vehicle license plumber
Company
7. Location where contents were disposed:
Sig ture f u Date
Signature of Ivjng Facility(or attach facility receipt) Date
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