HomeMy WebLinkAboutSeptic Pumping Slip - 110 CRICKET LANE 11/15/2016 Commonwealth of Massachusetts
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City/Town own o
DEC' ?
'016
System Pump in g Record
Form 4 � tAN�Lv
• °¢ HEALTH DEPAr"T P T
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.
A. Facility Information
Important;
When filling out 1. System Location:
forms on the /
computer,use -- ..j _ w.. .!a ��C 1'1
only the tab key Address
to move our e
cursor-d not ti ?_._....._.:._M1C�
use the return City/Town State Zip Code
key. 2. System Owner:
Name
......_ ..__._ _..__.._ _..._..__.._ _......_ _ _
Address(if different from location)
City/Town State Zip Code
cj -1 - 3 76 _ car 30
Telephone Number
B. Pumping Record __..._
1. Date of Pumping --.L...._.._...___ 2. Quantity Pumped: --
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): _...._....______ ___..._...._.__ _-,.._...
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
c)
6. System Pumped By:
ea "�
Name ' Vehicle License Number
Company �.._..w._
7. Location where contents were disposed:
BLS D
_. -_-__ ...._......_.
Signature of Haul___. er date
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