HomeMy WebLinkAboutSeptic Pumping Slip - 247 FARNUM STREET 5/2/2016 Commonwealth of Massachusetts
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City/Town of
Systern
Pumping Record NORTH AN DOVE
s �p
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but{hey y
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 information
Important:
When filling out 1. System Locatil
forms on the
computer,use
only the tab key Ad res
to move your
City/Town
cursor-do not
y n State Zip Code
use the return
key. 2. S stem Owner:
1
4 'p
Name
Address(if different from location)
--_
City/Town State Zip Code
Telephone Number
B. Pumping Record --
1. Date of Pumping —ate 2. Quantity Pumped:
D Gallons
3. Type of system: ❑ Cesspool(s) [�T Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 0,e` Yes ❑ No If yes, was it cleaned? ❑"f Yes ❑ No
5. Condition of System:
y Pumped By:
6. stem
Name Vehicle License Number
_ SwF ��i _ �_✓",�(�.,.,r�\,�_. ., __.--_. -.-.__.-..._.._-..._.
Company
7. location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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