HomeMy WebLinkAboutSeptic Pumping Slip - 226 REA STREET 4/5/2016 Commonwealth f Massachusetts
lugi n of
System qn
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 Syjt#rn Pumping Record must be submitted to
the local Board of Health or other approving authority within 14'days from the pumping date in
accordance with 910 CMR 15.351,
A. Facility Information
Important:when
filling out forms 1. System Location:
on the computer, �7
use only the tab
key to move your Address
cursor-do not NC) A yick t,e&
use the return Ci /Town
key, State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State' dip Code
Telephone Number
Pumping B. c®r -
1. Orate of Pumping Date 2. Quantity Pumped: Canons
3. Type of system: Cesspool(s) ', Septic Tank ® Tight Tank Ej Grease Trap
[) Other(describe):
4. Effluent Tee Filter present? Ye -No If yes, was it cleaned? ® Yes No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of auler Date
Signature of Receiving Facility Date
t5form4,doc•03106 System Pumping Record-Page 1 of 1
_ Commonwealth of Massachusetts
x City/Town of Merrimac
System Pumping Record
x
Forr-n 4
d14'iFPilil d {.1f.0&'a!"P,fr4.,}�/YaP�
DEP has provided this form for use by local Boards of Health. 0yF0edo 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
accordance with 310 CMR 15.351.
A. Facility Informati®n
Important:When
ruing out forms 1. System Location:
on the computer,
use only the tab c ', ►�-� b�._
key to move your Address
cursor.do not M21WVW Ale-) A H eJo U,e d' MA
use the return Cil /Town
key, Y State Zip Code
tab 2. System Owner:
Name
ream
Address(if different from location)
City/Town State Zip Code
K.sw•... ,J ...
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 9)No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6, System Pumped By:
Name Vehicle License Number
BORACZEK'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
'S
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record -Page 1 of 1
ICN Commonwealth f Massachusetts
�,..
City/Town f .Rn. � ECEI'VED
System i Record
Form 4 APR p�
z
2 3 2008
Befa u �
information must be substantially the same as that provided here. i :m
DEP has provided this form far use by local Boards of Health. Other fo ray
sing t is ;c 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:
When filling out 1. System Location:
forms on the
computer, use
only the tab key ddress
to m y move your
cursor-do not
use the return City/Town Stake Zip Cade
key. 2. System Owner: _..
Name ------- -
Address(if different from location)
Cit y
/Town State Zip C ode
Telephone Number
1. Date of Pumping bate 2. Quantity Pumped: dalions
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes -._.... if yes,was it cleaned? ❑ Yes ❑ No
5. Condition System: ? �
6. System um By:
..
Name ..H � Vehicle License Number
�,,
Company
7. Location w ere contentwgre d' sed:
-§gnatur�a,Atadl Date
t5form4.doca 06/03 System Pumping Record 4 Page 1 of 1
` t }r• �r t •.
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ggf1�`�kr�ylf
1'• 11• '�{{'�""„ r w -aye^.
W
�yi'#an iij t
-
I i 1
ha 'prdvtded this form for use by kcal Boards of Wealth. The System Pumping Record must
be submitted t0 the Kcal Board of Wealth or other approving authority.
X Facility inforr ation „
'*�-:tm�artant, `' '•� r;� � ,7�
oil .an the y catJcn
m Lo
u 4
,.� hen f Un out ste
g
.,. 'cam afar use,.
a.... .2
only the tab key Address
to move your:'
curve-d u of ' City/Town III � my µ � .
key s State
System Zip Code
Owner; ,.:
• M®
..' Nme a i,', I ('.!•., ' A I
Address(If different from location)
t ,
city
!Yawn'
r
Stat
Zp Code
�µ.
f'
Telephone N be
U mping Rocord
�t a"1�`I,�, Ju ✓
I
P
a 4 �
9 m.,
m^
,
um Date — >pate 2. qua nt ty Pumped: '
Ga Ions
'.Type of system: Cesspnol($) Septic Tank Tight'Tank
' ether(desc r be)r
4 Effluent T1,ee Fii,e, 'present? Yes o'
e a
w s it cleaned? Yes []' No
�` 6 ondit(on of Systgm;'
4
fir. SY ern Pumped Pyr .....
t I
4r ,,} a �r ;• {�, ;r; t Vehicle LnJceen/4e Number
t '.r Vht'.''J S `rr 4y�rrf tr,'�j�l�f •. cJ'1�
VW,
' Ij T �t' hl J � • tr't
r
, ` 1
.y � ���pifi�t�Hl�'�yW�' � r.1�o����JIYtrYr7s��ir � .'�• Y ..
7, Locaflpn where contents werg disposed;
yy
x y, Signature of Hauler,#� �..
Date
TTS
hUp Jfwww mas's.gcv/dap/water/approvals/t5fcrms,htm#inspect
t5foren4 dac+!)6/93 System Pumping Record-Page 1 of 1