HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 96 SUGARCANE LANE 7/18/2026 Commonwealtf� of Mass'achu etts
r
a City/Town of
Syt�rn Pumping Roc:orci
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but llrr,
information must be substantially the same as Mat provided here. Before using this form, check with your
local Board of Health to determine theform they use. The System Pumping Record must be submitted to
the local Board of Health or other �rpproving rau"hority within 14 days from the puf-nping data in
accordance with 310 C:MR 15.351,
H0USI front h_tck Side rn tr Irrf D
A. Facility Infort-nation BUILDING: front, back side rt_at left right
In7portant,whom DS=CK: under
oiling oiA forms 1 Syster-1 Location',
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B. Pumping Record
1. Date of Pumping ..__.. -__._.__. __-_.._ 2. Quantity Pumped.
Gallons
3. Component: Cesspool(s) Septic Tank( ❑ Tight -Tank ❑ crease Trap
❑ Other (describe): _ -_- __-
4. Effluent Tee Filter present? ❑ Ye/Cr,-f)
No If yes, was it cleaned'? E Yes n No
5. Observed condition of cornfonent fed:
6, System Pumped By:
Dave `Finn :ass 1AA C Mass 1AD31Z_
_. --\ lcle t �cen;e ,tuber
eakeson En(erpnses Inc,
Company
7 (_o ation where contents wearer disposed.
BLS[:
Sign ur Hauler Date ---- — — --- -- ---
Signalure of Receiving Facllit), (or afi rch facility re:ceip.) Da(e --
l5forrnkdoc- 11112 Syslem Purnl;)ing Record Paste 1 of 1