HomeMy WebLinkAboutSeptic Pumping Slip - 129 FOREST STREET 4/12/2016 Commonwealth of Massachusetts
_( City/Town of NORTH AN DOVE SACHUSETTS
System Pumping Record RECEIVED
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DEP has provided this form for use by local Boards of Health. he System Pumping Rec rd must
be submitted to the local Board of Health or other approving au' I agora rnt r�bsgDOV R
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use t 11<-'f C"IN t- '
only the tab key Address
to move your y /ar�.a ..( � ...aaJ State Zip Cod
cursor,do not City/Town/Town
use the return P
key,
2. System Owner:
Name -- --- - ---
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Address(if different from location)
City/Town State Zip Code
31"
Telephone Number
B. Pumping Record
1, Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe): b a
4. Effluent Tee Filter present? ❑ Yes ❑° o 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 Hauler Date
http://www.mass.gov/dep/water/approvals/t5fDrms.htm#inspect
t5formA.doc-06/03 System Pumping Record•Page 1 of 1
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FORM 4-SYSTEM PUMPING RECORD
CUMUER
SEP'ric & DPAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978) 774-2772
COMMONWEALTH OF MASSACHUSETTS
, 1WCASSAC11USETTS
SYS7TY M PUMPING RECORD
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SYSTEM OWNER: SYSTEM LOCATION: 1p
f p
DATE OF PUMPING: �
QUANTITY PUMPED: ! �� GALLONS
CESSPOOL: NO C7 YES L--�] SEPTIC TANK..: NO YES EZ
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO: Cr. ( , �
DATE: 7" INSPECTOR: '