HomeMy WebLinkAboutSeptic Pumping Slip - 216 REA STREET 4/5/2016 Commonwealth of Massachusetts
City/Town of
- System in g Recor
Form 4
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 within 14 days from the„pumping date In �o
accordance with 310 CMR 15.351. RECEI `�W
A. Facility Information 3 7014
Important:
When filling out 1. System Location: OVVP,d 1",)0 Vr�'h�t
forms on the � C'f Will
computer,use __. 14' e --
only the tab key Address
to move your r'%'G7 ✓�m� CTS�,- . � —--- --- tl '/ x '
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
car!z
Name
D Address(if different from location) ----- --_—_. —__ ---.---
City/Town -- — State - Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons i
1 Type of system: ❑ Cesspool(s) U,-Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --- —- ---- — -- ---
4. Effluent Tee Filter present? ❑ Yes [ fro If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6. System Pumped By:
Name — Vehicle License Number
Company
7. Location where contents were disposed:
® ®& A
Signature of Hauler Date
Signature of Receiving Facility - — ---- Date —
t5form4.doc•03/06 System Pumping Record-Page 1 of 1
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Systern' Purnping.Record
Form 4
DEP has provided this form for use by local Boards of health, The System Pumping Record mul
be submitted to the local Board of health or other approving authority,
. A..Facility Information
Important
NwnZ tlon:
forme on the ".,,
_.,
When filling out �System. oca�. � ..
computer,use
only the tab key t o move your
cursor-,do not ty State use the return I t ( C '�.
P
key, 2, Owner:
a
Name
Address(If different from location)
City/Town State Zip Code
Telephone Number
Pumping Record
1, Date of Pumping Day 2, Quantity Pumped:
allons
I.,Type of system; ® Cesspool($) Septic Tank ❑ Tight Tank
Other(describe);
4, Effluent Tee Filter present? ❑ Yes ❑ No If y6',-Was it cleaned? ❑ Yes ❑ No
5, Condition of System; ...,
6, Tst Pumped T
` ...... ^.,i ..
.y�
me Vehicle License Number
t C_Company
7, . Locatlo where contents were disposed;
Ignat of Hauer Date
http://www.mass,gov/depAvater/approvalsA5forms:htm#Inspect
t5form4,doc 06103 " System Pumping Record-Page i of
,'d'•r I
Earn
FORM 4 - SYSTEM PUNIPM RECORD
Commonwealth of Massachusetts
, Massachusetts
System Pumping Record
—SN-stem Owner ,.,stem Location
Date of Pumping: Q uantity Pumped: jC'-' `�€allons
Cesspool: No P Yes ❑ Septic Tank: No ❑ Yes
System Pumped by- _ License #:
Contents transferred to:
Date Inspector