HomeMy WebLinkAboutSeptic Pumping Slip - 101 CRICKET LANE 12/8/2016 -
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System 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 310CK8R15351.
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Important:When
filling out forms 1. System Location: TOM OF,MAO MANDOVER
on the computer,
use only the tab
key to move your xum
cursor do not
use the return -----------------
key. Qtw7m*n State Zip Code
2. System 0 �
me
dress(if different from location)
CityfTown State Zip Code
ephdne Number
B. Pumping Record
1. Date of Pumping Date Quantity Pumped.
8 Component: El Cesspool(s) |Yj'SepticTank ^l Tight Tank F1 Grease Trap
[] Other(describe):
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4� Effluent Tee ��r ��r0 � Y�.� No If yes, was it cleaned? El Yes F1 No
5. Observed condition of component pumped:
u. System ,"... -
Name Vehicle License Number
Stewarts S ptic 58 So Kimball St Bradford Ma
Company
7� Location where contents were disposed:
20 so mill atbnadfordmo
_
mgoam,amHauler Date
SiAn�mracvmm:e|vmgFamnty(m�taoxomiutymma,pt) Date
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