HomeMy WebLinkAboutSeptic Pumping Slip - 275 ABBOTT STREET 8/10/2016 RECEIVED
Commonwealth of Massachusetts
City/Town of.&LV,, AWJ&,d/)
Ekr ��OVER
ow"I OF
System Pumping Record iIEAOVI 0EPPJA`UAfJ"11'
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Ad ts
,ot
cursor-do i
use the return KAA-
key. Cityfrown
State Zip Mi
2. System Owner:
Name
Address(if different from location)
C 1 tyl I own State Zip Code
y 91./
Telephone Number
B. Pumping Record
1. Date of Pumping oat 2. Quantity Pumped-
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑
Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
S. Observed condition Of component Pumped:
6. System Pumped By:
2160
Vehicle License Number tCoMany
I
7. Location wy ere contents were disposed:
511
Sig a reofl-lauler
Date
%JIUFIU[Ure Or Waiving Facility(or Bi6Zii facility'receipt) Date
t5formAl.doc•11/12
System Pumping Record•page 1 of 1