HomeMy WebLinkAboutSeptic Pumping Slip - 1160 GREAT POND ROAD 6/15/2016 IL
Commonwealth of Massachusetts
Y
City/Town of K16W-4 RECEIVED
A System on
r`
Form 4
1'°0 Iq OF N(Ri nNDOV�:i°°�
DEP has provided this form for use by local Boards of Health, Other forms ma V�6k/6iuut`ineI
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 forms 1. System Location:
on the computer, 1
use only the tab //6 / a 2 a, - ' )✓ � ,
key to move your Address G -
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
Name
nzum '
Address(if different from location) - -
City/Town State
Zip Code
— &D
B. Telephone Number -"---
u In ec r
1. Date of Pumping 2. Quantity Pumped: 5a.)
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank a Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped B
_(-�" / � �)�✓ l��
Ns Vehicle License
Number
Company
7. Locatiorl where contents were dais o
a"
-- -- --- ---
u i ature r
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12
System Pumping Record•Page 1 of 1