HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 59 BANNAN DRIVE 8/4/2026 Jowl I U! 14VI u I n,1%4%0 V—
Commonwealth of Massachusetts SEP 8 2026
City/Town of
System Pumping Record Health Department
Form 4
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. Before using this form, check with YOL
local Board of Health to determine the form they use.The System Pumping Record must be submitted t
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, —C
use only the tab
key to move your Address
cursor-do not
use the return
key, City/Town state Zip Code
2. System Owner:
Name
Address[if different- -i-r-om
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ..2-,,Quantity Pumped:
Date _1" Gallons
3. Component.- F1 Cesspool( Septic Tank El Tight Tank n Grease Trap
Other(describe): -------
No If yes,was it
4, Effluent Tee Filter present? El es cleaned? 0 Yes E3 No
5. Observed condition,of component�Grnped:
6. System Pumped By:
_Name V_eh"i_c_1eUce_n__s_eNumber
C_
pa-do nnyZ"41.
7. Location wh re contents were disposed:
/7,
o�au Date
Signature of—Receiving Facility(or attach facility receipt) Date
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