HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 2 BANNAN DRIVE 5/26/2026 Commonwealth of massachusetts
Cily/Town of
System Pumping record
Form 4
DEP has provided this form for use by local Boards of Health, Other formi maybe used, but the
information must be substantially the same as that provided here. Before using this fbrm, 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 CN4R 15,351_
A. Facility Information
Important:when
filling out forms 1. System Location: JUN 2 6 2026
on the computer,
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use only the tab
key to move your Td—dress—
cursor-do not v", r"r,"c' rr,�
usa th retu M �('/�H)ealth Depailment
key. Cty/Town '�tate Zip-Code
2. System Owner:
r
Nate
Address(if different from location)
7CtyJTown state 7-1 P- e--
B. PUmping Record1. Telephone-Number
Date of Pumping aate 2, Quantity Pumped:
Gallons
3 Component: Cesspools) Septic Tank Tight Tank F7 Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? [I Yes 71 No If Yes, was it cleaned? Yes No
5. Observed condition Of component pumped:
6, System Pumped By:
7 "Y� e
Name Vehicle License Number
Wayne's Drains, Inc.
Company
7, Location,where contents were disposed:
z
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
I -F I