HomeMy WebLinkAboutSeptic Pumping Slip - 456 SUMMER STREET 4/11/2007 commonwealth .of"Massachusetts
City/Town of I
System Pum `In y p g Record
Form 4
DEP has provided this form for use by local Boards of Health. 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. " Syste( Location:
forms on the
computer,r, use 1 1
only the tab key Address ``,�� _
to mov your
cursor edo not
4 u yi ly y `'�_ AJ
use thereturn City/Town Stat Zip Code
kEy. 2. System Owner.
Name
Address(if different from location).
City/Town tat
Telephone Number
.B. Pumping ReGOrd
7
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 P-14-0 if yes, was it cleaned? ❑ Yes' ❑ No
5. Condi�io of e
mod_
6. 3 y stenj Pu ped By:"
a-
Name Vehicle t:icensa Number
Company "
7. Lacatl0 ere contents were � osed:;
' ._ .
signatu of aul r Date
h.ttp://www.mass.govidep/watertapptoval8/t5forms.htm#inspect
t5form4. oc•06103 System Pumpmg.Record•Page t of 1