HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 224 FOSTER STREET 6/4/2024 Commonwealth of Massac
husetts r1
City/Town of
System Pumping record
sw Form 4 �
DEP has provided this form for use by local Boards of Health. Other forms may be t the
information must be substantially the same as that provided here. Before using this form, th your
local Board of Health to determine the form they use.The System Pumping Record must be su fitted 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 _ � w.. .---._.__✓.. __w___ ___..
Important:When
filling out forms 1, System Location:
on the computer,
use only the tab - _ . . ._.. ___. .... ---------- _.. _ - ......
key to move your Address
cursor-do not AndOLRf
use the return ---..__ ___.._ ........ _..... ._ ..-._.. _ --._.
key. City[Town State Zip Code
s 2. System Owner: ,
....._
Name
r
Address(if different from location)
_........_ _ . ........... _ _.......-. ------ ....... .. _ _. _ _...
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Gate Gallons
3. Component: ❑ Cesspool(s) Eglleptic Tank ❑ Tight Tank ❑ Grease Trap
❑ tither(describe):
4. Effluent Tee Filter present? ® Yes No If yes, was it cleaned? ❑ Yes ® No
5. Observed con ion of component pumped.
6. System Pumped By:
Ngme Vehicle License Number
Company
7. Location wh e contents were disposed-
Si ore Hauler Date
Signatu of ing Facility(or ttach facility receipt) Date
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