HomeMy WebLinkAboutSeptic Pumping Slip - 78 SPRING HILL ROAD 9/26/2016 RECEIVED
OCT 7. I Nib
Commonwealth of Mal, ia d'lusetts
, Ci !Town of ��`�� ������=r:OR�H/°�IDOVER
$ stem
y Pumping Record
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
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filling out forrns 8 Stem LoC
on the computer, ati
key to only the
our Address
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p dress
cursor-do not
use the return '" ..„
key. Cihr oVM State Zip Code
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2. System Owner: „
Name
Address(if different from location) --
CitylTo,n State
Zip Cade
'telephone Number
B. Pumping Record
1. Date of Pumping -
Date 2. Quantity Pumped:
3. Component: El Cesspool(s) [Se Gallons
ptic Tank ❑ Tight Tank ❑ 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 By:
ld
a / Vehicle License Number
Cb�pany
7. Locatio where contents were disposed:
i
Signature of Mauler
Date
Signature of RecelVing Facility(or attach facility reoeipt) Date
t5form4.doc•11/12
System Pumping Record•Page 1 of 1