HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 78 VEST WAY 6/27/2025 � Commonwealth of Massachusetts
�WW City/Town of Town of North
I° System Pumping RecordRover
Form 4 JU
C 10 2025
DEP has provided this form for use by local Boards of Health. Oth r forms may be used, but the
information must be substantially the same as that provided here. ir�this form, check with your
local Board of Health to determine the form they use. The System Pumpinc F bmitted to
the local Board of Health or other approving authority within 14 days from the pumping a
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 Address - ......
cursor-do not s t
use the return _._._ ._...__._ __ __._ 6G ,_° ° 1 __-_. _ ...._. .__ l � __.._
key. City/Town State Zip Code
Q2. System Owner:
Name
Address(if different from location)
-.... ._..__.. _. . ---— -_-_._
CityfTown State _....--
Zip Code
/ ®7 j -
Telephone Number
B. Pumping Record
1. Date of Pumping -�._�__.___..,�.. �.�_�_ 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ❑Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _._........_ .... ...._.__..._._ . .____.
4. Effluent Tee Filter present? ❑ Yes ❑ No' If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: /
6. System Pumped By:
_. ------- _.__.._.._...._ _... _._.._._.
Name Vehicle License Number
Company '—
T. Location whe71,
contents were disposed:
6>�<,
Signature of Hauler pate
.......... ._. __.._....._ ._ .__.__
Signature of Receiving Facility(or attach facility receipt) pate
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