HomeMy WebLinkAboutSeptic Pumping Slip - 984 TURNPIKE STREET 4/13/2009 Commonwealth of Massachusetts
RECEIVED System
Pumping Record
Form 4 JUN '11 2009
®EP has provided this form for use by local Boards of Health. ®th rifut e
n t
information must be substantially the same as that provided here. efd�f' singA i � he k with your
local Board of Health to determine the form they use. The System Pumping ecor' `"must°"b-6 ubmitted to
the local Board of Health or other approving authority,
A. Facility Information
Important:
When ruing out 1: System Location:
forms on the ''� r C
computer,use j�
only the tab key Address
to move your
cursor-do not CitylTown Statem� _ Zi
use the return P Code
key. . System owner:
0
V rt AA.I 1
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
Pumping B. Record
1. Bate of Pumping Da / 1 2. Quantity Pumped:
Gallons
3. Type of system: Ej Cesspool(s) Septic Tank ® Tight Tank
Ej Other(describe):
4. Effluent Tee Filter present? ® Yes No If yes, was it cleaned? ® Yes ® No
5. Condition of System:
6. System Pumped By:
P GEC' 2U 5"�`}/�.
Name Vehicle License Number
11 2
Company
7. Location where contents were disposed: L-�J
S 04 ture oAduler hate
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