HomeMy WebLinkAboutSeptic Pumping Slip - 61 WINDSOR LANE 4/28/2008 Commonwealth of Massachusetts
City/Town of NORTH �m"
4 System Pumping Record
Fora 4 MAY
DEP has provided this form for use by local Boards of Health . T d '
i` r�r a �e rd must
be submitted to the local Board of Health or other approving aut ort
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-donot
use the return City/Town State Zip Code
key. 2. System Owner:
Name
rerun �
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1-i rr
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) J Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
c°" (_,r_
J
6. System Pumped By:
Name r4., Vehicle License Number
yi Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/w"ater/approvals/t5forms.htm#inspect
t5form4.doc-06/03
system Pumping Record Page 1 of 1