HomeMy WebLinkAboutSeptic Pumping Slip - 315 SOUTH BRADFORD STREET 2/17/2009 Commonwealth of Massachusetts
N
r City/Yawn of Nom ANCOVER
System u pin g Recor
r` Form 4
M
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 Pump n�t� f 11a itted to
.!n
the local Board of Health or other approving authority within 14 days ram ffiaa in
accordance with 310 CMR 15.351.
A. Facility Information "&
When filling out 1. System Location: - r i p ► t�°H[5 ODAfRM NTPf
Important: N, CO NOR1 V 1
forms on the
computer, use
VN t 5 r C
only the tab key Ad re
to move your
cursor- not
use the return CitylTown Stake Zip Code
key. 2. System Owner:
VQ Name
+ Address(if different from location)
City/Town State Zip Code
. ` o
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: � C —
Date Gallons
3. Type of system: ❑ Cesspool(s) @(Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [�J''No° „ � � Wpli I paned? ❑ Yes ❑ No
5. Condition of System: �l � �C! I
6, System Pumped By;
GI Y
Name Vehicle License Number
Am -
Company
7. Location where contents were disposed:
�w ,I o ,
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc,03/06 System Pumping Record•Page 1 of 1