HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 997 DALE STREET 4/17/2025 Commonwealth of Massachusetts TORn Of%rth A'doer
23
City/Town of J, APR AVIJ0 2025
System Pumping Record
-10a;jj7 t)epc e t
Form 4
077 17
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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, r
use only the tab -------------- -- __---
key to move your Address
cursor-do not e 57
use the return ........... ----------- q ..............
key. City/Town State Zip Code
VC] 2. System Owner:
........
Name
...............__'.._.___'.__............. ---------------- ............... ...................
Address(if different from location)
hy own____ -State-"--- -Zip----Code- ''-----------
C4=--__-------------------
Telephone Number
B. Pumping Record
71
1. Date Of Pumping Date-- 2. Quantity Pumped: Gallons
3. Component: 0 Cesspool(s) [R"Septic Tank F-1 Tight Tank n Grease Trap
Fj Other(describe): ____------------ -- ------- -...............
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? ❑ Yes [] No
5. Observed condition of component pumped:
C';10 J
................ .........----------- ............... ...........
6. System Pumped By:
.............. ---------- -------
Name Vehicle License Number
VY'A
Company
7. Locrtion wher ontents were disposed
C -------------- ------------------ ...........
Si rra "
f Iia r Date
----------
Sig t .01 wing feacility(or attach facility receipt) Date
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