HomeMy WebLinkAboutSeptic Pumping Slip - 946 OSGOOD STREET 5/18/2016 Commonwealth of Massachusetts
CityrFown of
System Pumping Record
-ti
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 filling out 1. System Location:
forms on the C f�
computer,use
only the tab key Address
to move your
y"(G:
cursor-do not
use the return Cily(Town St2rte Zipe
key. 2. Systems Owner:
VQ _c !` _ ._ -- ? s. _ /% I ....__ --
Name
"°'° Address(if diNerent from location)
CitylTOwn State J ry } Zip Code
Telephone Number
B. Pumping Record -
1. Date of Pumping Oa ~✓( n(('—-- 2. Quantity Pumped: Gallon `
Lallans
3. Type of system. ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank r'ea se
❑
Other(describe)-,
4. Effluent Tee Filter present? ❑ Yes lla If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste
6, System P/u�mp/end" By: y
q
Name LC l ." _. ---_—• .__._ _Vehicle Lnst e�e
e Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
BRADFORD, MA 018
Signature of Receiving Facility Date 7 372^
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