HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 BROOKVIEW DRIVE 4/30/2025 Commonwealth of Massachusetts ro Wn forth A,do
City/Town of per
System Pumping Record kA y
5,2025
Form 4
DEP has provided this form for use by local Boards of Health. Othe�1r.nw"o ed, but the
information must be substantially the same as that provided here. Before using thIM ith your
local Board of Health to determine the form they use.The System Pumping Record must beitted 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 CV, -V-V Ev ...........................
r --—------------
key to move your Address
cursor-do not
use the return ----------
key. City/Town State Zip Code
2. Sy9 Owner:
N , ......................... ............... ...................... .......... ---------------
----------------
Address(if different from location)
-&It-y--/-T-o-wn- -State -Zip- -6 o-d-e
75
Telephone Number
B. Pumping Record
--4y
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) Zkleptic Tank M Tight Tank E] Grease Trap
F-1 Other(describe): I- --- ................. ------------------ ----................................. ---
4, Effluent Tee Filter present? n Yes n No If yes, was it cleaned? Ej Yes ❑ No
5. Observed condition of component pumped:
CADcl 1-1-1 ----
6. System Pumped By:
e rc
................................. ............ ------.......... ...................... ................
Nam r Yehide License Number
17
Company
mpany
7. Location wher ntents were disposed:
--------------- ----------------
Signatu of H uler Date
ignature f Re iv attach facility receipt) Date
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