HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 OLYMPIC LANE 9/16/2025 Commonwealth of Massachusetts Town Of " ^l
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System Pumping Record
,. Form 4 OCT 6 2025
DEP has provided this form for use by local Boards of Health. er fp s ay be used, but the
information must be substantially the same as that provided hA�# eck with your
local Board of Health to determine the form they use. The System Pumping Record must b submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CN1R 15.351.
A. Facility Information
Important:when _
filling out forms 1. System Location:
on the computer,
use only the tab l /
key to move your Address
cursor-do not
use the return _ - 1..�,/Cyr ram....._......
key. City/Town State Zip Code
Q2. System Owner:
�p
Name
ran
A - ... _. _- ------ . _. .........- ------ -.... _.__ .. -, __._..................
_....
Address(if different from location)
-- ------------_._— _.......... ---.. ..- - ___._ .._..
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ---- ---- 2. Quantity Pumped: ----
Date Gallons
3. Component: ❑ Cesspool( ❑Septic Ta ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _.----------_ __-._. e ____
4. Effluent Tee Filter present? ❑ Y (❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
._ -
00 C-
._-
6. System Pumped By:
Name —, Vehicle License Number
CA
Company
7. Location whe e contents were disposed:
Signature of�_�`'
Ha er Date
.__...._..._..__..._.--------_ _...__.---- ._...__._._.._...__._..___....___._..._.....__..- ___...._......__...._...._.___...----...--------__..___..__.__....._..,..__..- ____---
Signature of Receiving Facility(or attach facility receipt) Date
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