HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 WHITE BIRCH LANE 4/30/2025 Commonwealth of Massachusetts Town of'Orth over
City/Town of 4/,�r�- 14-rvloaf MAY 5 2025
System Pumping Record
............ Form 4 Departrnent
DEP has provided this form for use by local Boards of Health. Other 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 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 -------
key to move your Address
cursor-do not
use the return ------ ...............
key. ity/Town State__
tate Zip Code
2. System Owner:
---------- ----------- ----------
CNM
Name
........................ ................ ........................... ----—---------------------- .. ..........
Address(if different from location)
----------- ................ .................
City/Town State Zip Code
vze(
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component- Cesspool(s) Pr"Septic Tank ❑ Tight Tank F-1 Grease Trap
❑ Other(describe): ...........
4. Effluent Tee Filter present? n Yes BING If yes, was it cleaned? M Yes ❑ No
5. Observed Condit' n of component pumped:
—----------- ----------- ---------
6. System Pumped By: -7
...........
me Vehicle License Number
D
Company
7. Location wh ents were disposed:
......................----------- ..................... ............... ........------------- -------- --------
Si 9" ure of ler Date
---------------- -—------------ ----------
'Sig-nature Receii g Facility(or a h facility receipt) Date
t5forrn4.doc-11/12 System Pumping Record-Page 1 of 1