HomeMy WebLinkAboutSeptic Pumping Slip - 93 CRICKET LANE 5/3/2017Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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01": NORTH PI,M0\15,.P.
k-FLALtH 1YEPPATMENT
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 Pumpin9 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
I - Cc '(- k- 0 - Y")
computer, use
only the tab key Address
to move your
cursor - do not A/0 .4 (0 t) C
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address (if different from location)
r kcic
City/Town
B. Pumping Record
1. Date of Pumping
State Zip Code
617- 5,x-)- /)e/e
Telephone Number
2. Quantity Pumped:
3. Type of system: Cesspool(s) Ej Septic Tank 0 Tight Tank
El Other (describe):
6/- / 7
Date
Xa)
Gallons
4. Effluent Tee Filter present? M<'es El No
5. Condition of System:
If yes, was It cleaned? j-"fe;No
. System Pumped By:
Name
( 2 C
Company
7. Location where contents were disposed:
6_
Vehicle License Number
Signature of Hauler Date
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1