HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 46 WHITE BIRCH LANE 6/5/2024 10W/7 of
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Commonwealth of Mass chusettsv �"
City/Town of �
- r System Pumping Record
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Farm 4 E?
DEP has provided this form for use by local Boards of Health. Other farms may be used, jt the
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
computer,
y
1. System Location:
tion:
o
use only the tab _
key to move your Address
cursor-do not 7
use the return _ ._ _..
key. City/Town State Zip Code
stem Owner:
VQ
.. _ .._. ........... -
Name
Address Of different from location)
City/Town State Zip Code
Telephone Number
_ _
B. Pumping Record
1. hate of Pumping p 11 ate allons 2. Quantity Pumped: _ ....... . __ ..._.....
G
3. Component: ❑ Cesspool(s) MSeptic Tank ❑ Tight Tank ❑ Grease Trap
n Other(describe):
4. Effluent Tee Filter present? ❑ Ye�No If yes, was it cleaned' ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
co (TO
.f M
.._....... .........__
N me ehicle License Number
Company
7. Location where ntents were disposed:
......-._ __.. �....
Sin� r�of ...,��,gu _, � ._ _...__ m.... ___ ....__.__ Date
g au r
.... _ ........ -.---------- _.. ... �............
Signature of eivi acility(or at ch facility receipt) Date
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