HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 88 HAY MEADOW ROAD 4/17/2025 Own of'Vorth�L\ Commonwealth of Massachusetts 4ndOver
City/Town of APR 23 2025
System Pumping Record
"eath Depcjrt
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
,,rjt
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 Add
cursor-do not
6
use the return
key. City/Town state Zip Code
2. System Owner:
4e,
Name
.......... .................................................................................. .................. ----------------------------- ..................... ------.........................................
Address(if different from location)
-d
ity/Town State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping Date- 2. Quantity Pumped: Gallons
3. Component: n Cesspool(s) eptic Tank ❑ Tight Tank R Grease Trap
E] Other(describe): - ....... ............................. .....---------------------------
4. Effluent Tee Filter present? El Yes Q/No If yes,was it cleaned? f-1 Yes ® No
5, Observed condition of component pumped:
opcp
----------...............- ....................
6. System Pumped By:
-111-t�"".rA........... ------I-------
p ----------
N me Vehicle License Number
p
Company
7. Location where contents were disposed:
-----------------
Signature of c Yin �h Date
Signature a6ie'r Date
Facility(or facility receipt)
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