HomeMy WebLinkAboutSeptic Pumping Slip - 100 TUCKER FARM ROAD 11/10/2016 Commonwealth of Massachusetts RECEIVED
City/Town of Merrimac
System Pumping Record tjopV ANDUVE.R
Form 4 �j qf�ppRTME11�1'
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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 --I 1-1�A rn
key to move your Address
cursor-do not NO - A r\ck v-e,;— MA 01860
use the return City(Town State Zip Code
key.
2. System Owner:
Name
1-0
Address(if different from location)
City/Town State Zip Code
1-4"— 2�)O— 629`0
-Telephone Number
B. Pumping Record
1. Date of Pumping 16' 2. Quantity Pumped: 6�00
Date Gallons
3. Type of system: ❑ Cesspool(s) [a-18-eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -—--------------
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
BORACZEKS SEPTIC & DRAIN
Company
7. Location where contents were disposed:
z- D
Signature of Hauler Date
Signature of Receiving Facility Date
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