HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2 BRECKENRIDGE ROAD 4/30/2025 Commonwealth of Massachusetts Of North A ndo Ver
City/Town of
System Pumping Record W y 52025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may e
information must be substantially the same as that provided here. Before using this form, c t 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab C/
key to move your Address
cursor-do not
use the return .......
key. City/Town State Zip Code
VQ 2. Sy t mOwner:
namel
................ .............................. .................
Address
(if different from location)
--------------- ............... ...................
City/Town State Zip Code
72,
------------
Telephone Number
B. Pumping Record
1. Date Of Pumping -data.__ -----------------❑-- 2. Quantity Pumped: Gallons
I . ........ —-------
3. Component: f-1 Cesspool(s) R"Septic Tank R Tight Tank F-1 Grease Trap
F-1 Other(describe): ---------------------------------
4. Effluent Tee Filter present? ❑ Yes [] No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condi'on of component pumped:
..........
6. System Pumped By:
Vehicle License Number
'4
ompany -17
7. Location w er c ntents were disposed:
. ............... - —---------------
110
........... ----------------------
-'z
-Sig-natu o a Date
S 11 i I g 11 n I a I t-u-r of R,ec `ving ci,I i,t,y or attach acHity receipt) Date
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