HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 12 BARCO LANE 5/27/2024 Commonwealth of Massachusetts f
City/Town of L ��
System Pumping record
W. Form 4
w, 42025
' ec,
LIEF has provided this farm for use by local Boards of Health. tither forA% used, but the
information must be substantially the same as that provided here. Before using check with your
local Board of Health to determine the form they use.The System Pumping Record mu pbmitted 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, r
use only the tab ..� .... .. ":.
key to move your Address
cursor-do not _ '.. .._. . ...w,. ..._....._, _ _ ._.__ e
use the return _
key. Ci y own State Zip Code
2. System Owner:
W
Flame
Address(if different from location)
_.._.... .. .. ....
City/Town _ ... State Zip Cade
Telephone Plumber
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? ❑ Ye No If yes, was it cleaned? Q Yes R No
5. Observed con ition of component pumped:
6. System P roped y:
�.
Flame y/` Vehicle t„ioe Plumber
Company
7. Loc tion w er contents were disposed:
Sig 11.1 rrature o auler Date
Signature f R ing facility_(prdftach facility receipt) Date
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