HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 73 CHRISTIAN WAY 4/17/2025 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 Of North A/40 Ver
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 tAp r(fjo check with your
rrin4 c ec wi
local Board of Health to determine the form they use. The System Pumping Recor r !pbmitted to
the local Board of Health or other approving authority within 14 days f the pumping date i
accordance with 310 CMR 15.351. Fre'111h
C
A. Facility Information I JU/7t
Important:When
filling out forms 1. System Location:
on the computer, (J) rA
use only the tab -------------— -------------- ------
key to move your Address
cursor-do not AAA-
use the return ---------------------- ---------------------------
key. City/Town State Zip Code
2. System Owner:
'A
---------------- ............... ............ ..............................
Name
.......... .................... ............................. ------ ..............................
Address(if different from location)
.................................. ----—------—-------------------- ...........................................
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 11 Date 11 I 2. Quantity Pumped: Gallons
1 Component: ❑ Cesspool(s) D"§eptic Tank ❑ Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? F] Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. ObrrVed con ition of component pumped:
----------------- .......... ----------------- ----------
6. System Pumped By:
7
----------------- ..........
Name Vehicle License Number
Company
7. Loc�bon where contents were disposed:
- -------------------------
---------------------------------- ... . . ................. --------
Date
W uler 2
u-r a"'0 - ---------------------
Si nature f-k Facility(or attach facility receipt) Date
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