HomeMy WebLinkAboutSeptic Pumping Slip - 143 LACY STREET 4/30/2016 f^
Commonwealth of Massachusetts
City/Town of
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 flung out Location
forms on the
computer,use System
Zi
State
only the tab key Addre s
y J
to move our ty a k
cursor-do not Ciwn p Cod
use the return
key. 2, System Owner-
Name
Address(if different from location)
City/Town Stale — Zip Co e
#'6 6136
Telephone Number
B. Pumping Record
1"
1. Date of Pumping Da Quantity Pumped:
Gallons -
3. Type of system. ❑ Cesspool(s) °" eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _ - - . ..
4. Effluent Tee Filter present? °``fes ❑ No If yes, was it cleaned? P,"Yes'�❑ No
5. Condition of System:
6. System Pumped By
Name Vehicle License Number
Company
7. Location where contents were disposed;
Signature of Nauler Date
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—at - -f.------ ------
Signature of Reserving Facility Date
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