HomeMy WebLinkAboutSeptic Pumping Slip - 136 STONECLEAVE ROAD 4/30/2008 Commonwealth of Massachusett
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System Pumping rd
Form 4 � ;� �edi. G
DEP has provided this form for use by local Boards of Health. The System Pu�P.jrtgl,., ecord must
p p g authority.
be submitted to the local ward of Health or other a rovin authari
A. Facility information
ation
Important:
When filling out 1. System Location:
forms on the
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computer,use
only the tab key Adoress ..
to move your .: . �.. ��:��� (° ak-.
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
a �
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Dumping Record
1. Date of Pumping 2. Quantity Pumped: i t.,.• f
Date Gallons
3, Type of system: ❑ Cesspool(s) P91 Septic Tank ❑ Tight Tank
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes `tVa If yes, was it cleaned? ❑ Yes ❑ No
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5. Condition of System:
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6. System Pumped By r ..,.
E e w
Name
�, Vehicle License Number
Comparf'y ..
7. Wcation where contents were disposed:
a:F" L
Signat,urb.,of Hauler Date
http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
t5form4,doc•06/03
System Pumping Record•Page 1 of 1