HomeMy WebLinkAboutSeptic Pumping Slip - 45 BRIDGES LANE 2/5/2012 Commonwealth Of M sacl-i s tt �tw
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ity/ Own Of Merrimac
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System in Record ` a �`
Form 4 A
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DEP has provided this form for use by local Boards of Health. t the
information must be substantially the same as that provided here. Before using this form, 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 CMR 15.351.
A. Facility Informati®n
Important:When
filling out forms 1. System Location:
on the,computer, �7
use only the tab Y Y, --
key to move your Address
cursor-do not M VPA(S &[a T�� f 4 U� ( _ — — — MA City/Town State Zip Code
--- -- - MIN
use the return
-- --- -------------
key.
2, System Owner:
raa M r (” ,Gi c
Name -- —
renrn
Address(if different from location)
City/Town State Zip Code
t
Telephone Number
B. Pumping Record
1, Date of Pumping Da 2. Quantity Pumped:
Gallons
---------------------
3, Type of system: ❑ Cesspool(s) 'NI-Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): _.......
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6, System Pumped By:
Name Vehicle License Number
BORACZEK'S SEPTIC & DRAIN
Company -
7, Location where contents were disposed:
0
�(o
Signature of Hauler Date
Signature of Receiving Facility Date
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