HomeMy WebLinkAboutSeptic Pumping Slip - 26 DELUCIA WAY 1/9/2017Important: When
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Commonwealth of Massachusetts
City/Town of flytdMA
System Pumping Record
Form 4
REC
LAN 0 9
TOVVN OF t',10f."),"1"1-1ANDOVETZ;
HENTcH DEPARTiMINTr
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
1.
System Location:
2.11A) C
AddrTs
OcilA PVI\ CA \./ QA fit
City/Town State Zip Code
2. System Owner:
CitY
Name
Address (if different from location)
Ct
eiA t
City/Town
B. Pumping Record
1. Date of Pumping
3. Component:
State
Telephone NuMber
Zip Code
Ifi,;(y) C9
2. Quantity Pumped:
EJ Cesspool(s) I2 Septic Tank
0 Other (describe):
Gallons
0 Tight Tank 0 Grease Trap
4. Effluent Tee Filter present? 0 Yes El No If yes, was it cleaned? El Yes C] No
5. Observed condition of component pumped:
6. System Pumped By:
k,s,tZCr-,P1
Name
tk-1 414\
Cornpa y
7. Location where contents were disposed:
')
Sign ture of ule
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
t5forrn4.doc• 11/12
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