HomeMy WebLinkAboutSeptic Pumping Slip - 545 WINTER STREET 1/17/2017 FZEC,EIVED
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SYstem Pumping Record FEMD-1
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the
lnfbrm'ation 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 kcal Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.351.
A. Facility Information
Imporaft WM
#Ulng out forms 1. System Location:
on the co"uter,
U"only ft tab W �,,r le,4
key tomove r Add
Cursor do noyou
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use the return A71a+ A, IM
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State Zlp Code
2. SysteZOwner
Name
City/Town Own State
—Zlp Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped: >
Gallons
3. Component: El Cesspool(s) M Septic Tank 0 Tight Tank ❑ Grease Trap
0 Other(describe):
4. Effluent Tee Filter Present? 11 Yes ❑ No If Yes,was it cleaned? ED Yes E3 No
5. Observed condition of component Pumped:
6. System Pumped By:
i,
a vehicle lice n9eNumber W
Company
ompan�y
7. Location where contents were disposed:
4 Sig aumv
X/11 Mau
w Date
",
u'VIIOIUFCUTKOMvfngFacllky(or attach fadiftyre�celpt)
Date
11MMAdOc-11/12
System Pumping Reoord-Page 1 of 1