HomeMy WebLinkAboutSeptic Pumping Slip - 157 LIBERTY STREET 5/2/2016 Commonwealth of Massachusetts
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Systern Pumping Record NORTH -r,
PIr�F �lfr�r�
y❑ Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but
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 Informatrcan-- -- -
Important:
When filling out 1. System Location:
.. -- ..
(orrns on the
computer.use ._..: d
only the tab key Address .1. ._ Slate /t _ Zip C de�
o move your /y1 Y Vt(r ..._,
cursor-do not
use the return City/Town p
key. 2. System Owner:
Name
Address(If different from location)
City/Town State Zi Code
Telephone Number
B. Pumping Record --- — - —
� ' , ate_❑
--
1, Date of Pumping — -- 2. Quantity Pumped:
Da e r__.......---.._.
Gallons
3. Type of system. ❑ Cesspool(s) Q,15reptic Tank ❑ Tight Tank ❑ Grease Trap
C_7 Other(describe):
4. Effluent Tee Filter present? ❑"(�es ❑ No If yes, was it cleaned? ❑°}"'Yes ❑ No
5. Condition of System: �� J
6. System Pumped By - _--_-- --�❑ �
f ,L. l
Name Vehicle License Number —
Company
7. Location wh I
At¢s °d.sled:
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� to
""i
—gnature of Pi
Si �t Kati `�
Signature of Receiving Facility Date
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