HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 496 WINTER STREET 12/5/2024 Commonwealth of Massachusetts Of IVOrth 4ndoVer
City/Town of .. i �,er
MAY 5 2025
System Pumping Record
Form 4
Health Q
DEP has provided this form for use by local Boards of Health. Other forms may be?Pe@,Qn"t
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 "d'1'y'L>L,,e,-"- 2
usethe return ......... ............................-- 111--- "I��ll,",.�,.�o�l./�,�� -F-�J-1- .---
key. City/Town State Zip Code
2. System Owner:
CA
Name
...........
Address(if different from location)
--State"-" Z--i p-- o d-a...........
Telephone umber
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) R'Septic Tank Tight Tank ❑ Grease Trap
F-1 Other(describe): ..................... ..............................................------- - --- -----------------
4. Effluent Tee Filter present? ❑ Yes n No If yes, was it cleaned? n Yes No
5. Obse d condition(f component pumped:
------------------- ........... .............................
6. System Pumped By: q f 7 6
.................
N
Vehicle License Number
'Company-
7. Location wher c tents were disposed:
Date
............ ........... .......................
Signatu of, uler ,,
Si n a tu R eivingF iliti(or attach facility receipt) Date
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