HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 97 COMMERCE WAY 12/17/2024 s
Commonwealth of Massachustts -
rz City/Town
System Pumping Record �
Form 4 i
D EP has provided this form for use by local Boards of Health johher forms may be used, but 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 fr the punI ping date in
accordance with 310 CMR 15,351.. I� the ot,
NOrth An do
Var
A. Facility information
Important,When
FEB32025
filling out forms 1. System Location: i
on the computer, ("
use only the tab ... (
key to move your Address ��"���
cursor-do not , , � ,,, . �a en t _
use the return key. Gky/Town State Zip Cade
2. System Owner:
w Name
YL
Address(if different from location) i)
" i ii
City/Town State " _ Zip Code
Teleph&e Number
B. Pumping Record
I
1. Date of Pumping Date 2, Quantity Pumped: -----
,1 Gallons
3. Component: ❑ cesspool(s) Septic Tank + ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes,�as it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
°
{
6. System Pumped By: ;
Name Vehicle license Number
Wayne's Drains, Inc.
Company
7, Location where contents were disposed: ,
� , ..(- 1 .. . r"
ry' i
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date I