HomeMy WebLinkAboutSeptic Pumping Slip - 208 OLD CART WAY 8/8/2016 Commonwealth of Massachusetts
QL fi
City/Town of
System Pumping Record ,4` € °
F
Form 4
1 I
DFP has provided this form for use by local Boards of Health. Other forms tray'be used, b.ff.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.
A. Facility information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to moue your
cursor-do not CityfTo" State Zip Code
use the return
key. 2. System Owner:
Name
rears Address(if different from location)
Cityrrown State Zi Code
Telephone Number
B. Pumping Record �,r—✓r����� ^��,
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condit'o of System:
6. Syste
Name �_ � Vehicle License Number
Comp ny-
7. Location ere conten we 'sposed:
Sign re uti Date
0orm4.doe-06103 System Pumping Record•Page 1 of 1
Commonwealth_of Massachusetts
City/Town of [
System Pumping Record
o JI.JN 1 20r=
Form 4 1
DBP has provided this form for use b local Boards-of Health.- The System Pumping Record p Y m d must
be submitted to the local Board of Health or other approving authority.
A. Facility information
Important:
When oiling out 1. System Location
forms on the �1
computer,use
only the tab key Address r r
to move your x � �
cursor-do not
use the-return Ci#ylrown State Zip Code
key. 2. System Owner:
Name
Address(i(different from location)
Cityr own Slat 5 r
Cad
Zip e
Telephone Number
B. Pumping :Record
1. Date.of lumping pate 2. Quantity`Pumped.
Gallons
3. Type of system: ❑ Cesspool(s) CrSeptic Tank- ❑ Tight.Tank
❑ Other(describe):
4. Effluent Tee f=ilter present? ❑ Yes No If yes, was it cleaned? ❑ Yes"❑ No
5. Conditio of System:
6. System Pupped BV!
Name Vehicle Licens-Number
Com an
P Y
.7. Location a contents we ' posed:
Signal of a er Date
http:l/www.mass.gov/dep wat r/a proval81t5forms.htm#inspect
t5form4,dac•06103 Systern'Pumping Record•Page 1 of i
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:left front of louse
le. '6
DATE OF PUMPING: �>`� , QUANI,ITY PUMPED : fob GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD.CONDITION _ FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: L_ JJJ
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