HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 984 TURNPIKE STREET 5/29/2024 A,V. h,4
Commonwealth of Massachusetts over
City/Town of N o
w System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, bu
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 r
use the return ____
key. City/Town State Zip eode
2. System Owner.
.. ____.._. .__.____ . . _..__ _..---. . ._._ ---_ __Name
._.. __ ---- ._
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 ❑ Grease Trap
❑ Other(describe): --.._.. _ __.
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition ndi tion of component pumped:
6. System Pumped By:
__..._ _----------------
Name Vehicle License Number
al
Company
7. Location here contents were disposed:
Si atur of Haule� Date
_ a' ._..- _ ..._._.__ __._ -..._ __._... ------
Signature
f Receiving Faciii (or attach facility receipt) Date
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