HomeMy WebLinkAboutSeptic Pumping Slip - 25 HOLLOW TREE LANE rya
Commonwealth of Massachusetts
City/Town of
a
stem Pumping Record
Form
64 J
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 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.
A. Facility Information
Important:
oro
When
ms filling out 1. System Location:
computer, use
only the tab key Address
to cursor�danot City/Town ate C
use the return p
key. 2. System Owner:
VQ Name -- - -
Address(if different from location)
City/Town State ,ip code
o Number
Telephone
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped. Gallons
3. Type of system: ❑ Cesspool(s) ❑'°"aeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0.,t46µ.. If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: , .
r
s. Syster �Pumped By
Name ;- Vehicle License Number
Company
7. Location wh r contents were s osed:
,Wwniw+
Sin auler Date
t5form4,doc-06/03 System Pumping Record a Page 1 of 1