HomeMy WebLinkAboutSeptic Pumping Slip - 445 FOREST STREET 3/7/2016 Commonwealth of Massachusetts
City/Town of
I rd hAll� "I'll) 2(10(3
System p
Feral 4
,
DEP has provided this form for use b local Boards of Health.. The System Pumping Record .;
p Y .mwM. .A p .�n ..,must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When filling out 1• Sy5t m L pC t1
forms on they
computer, use .
only the tab key Address � •-- ^^ --�-
_..
----
to move your
cursor-do not — --- --------- --- — — _
-- ----------- -----
use the;return CitylTown State Zip Code
.key.
2. System Owner:
Name —----- — ---
Address(if different from location) -----
il-wrrown St - — ---- — ----
Zi "ode
Telephone Number
. Pumping Record
1. Date of Pumping Date --- — 2. Quantity Pumped: — --
Gallons
3. Type of system: ❑ Cesspool(s) Q°Septic Tank ❑ Tight Tank
❑ Other(describe): --— — --
4. Effluent Tee Filter present? ❑ Yes P,'�o If es was it cleaned?
Y E] Yes ❑ Na
5. Condition of System:
o�V�\ .a D
6. System Pum ed By
—
..- Vehicle License Number
Company -- -- - —
.7. Locatio/n ere ontents 7_w- re di ed:
Sig lh–au ler -- pate -- - —
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of 1