HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 166 GRANVILLE LANE 11/17/2025 Commonwealth of Massachusetts
City/Town of
TO" Of**Ando System Pumping Record ve,
Form 4
NOV 17 2025
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. BeN6,
local Board of Health to determine the form they use r %m, check with your
the local Board of Health or other approving authority* The System Pumping9
WU"fbitted to
accordance with 310 CIVIR 15.351. within 14 days from the Pumping date in
A. Facility information
Important:When
filling out forms I. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
key. CItyl I own
State
2. System Owner: YIP C—od-e-----
LIC)UL C,,Q.
Name
Address(if different from location)
Cityi I own
Skate 21p�Cade -------
B. Pumping Record Telephone Number
I. Date OfPumping
bate Quantity Pumped:
Gallons
3. Component: Cesspool(s) Septic Tank ❑ Tight Tank n Grease Trap
D Other(describe):
4. Effluent Tee Filter present? El Yes n No If Yes, was it cleaned? n Yes F1 No
5. Observed condition Of component Pumped:
6. Stem Pumped By:
A
NaTe
Vehicle License Number
Company
7. Location where contents were disposed:
Sign of Hauler
�
Signature of Receiving Facility(or attach facility receipt)
i pate
t5lbrm4.doc-11/12
System Pumping Record•Page 1 of 1