HomeMy WebLinkAboutSeptic Pumping Slip - 1337 SALEM STREET 5/3/2017Commonwealth of Massachusetts
City/Town of
System Pu ing 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.
A. Facility Information
use the return City/Town
key.
Important
When filling out 1. System Location:
forms on the
computer, use / 3 3 7 ,5 le 1-r) '-/
only the tab key Address
to move your /VO , A (tch Ve (-
cursor - do not
2. System Owner:
I? CI
Name
Address Of different from location)
r-nq
State
Zip Code
City/Town
Pumping Record
State Zip Code
7 Jo
Telephone Number
/ 3 -
1, Date of Pumping 2. Quantity Pumped: / gip()
Date Gallons
3. Type of system: D Cesspool(s) (erSeptic Tank D Tight Tank
n Other (describe):
4. Effluent Tee Filter present? Ej YevNo If yes, was it cleaned? 0 Yes No
5. Condition of System:
6-00C-
6. System Pumped By:
Name
80 rrAcz.e k e 4
Company
7. Location where contents were disposed:
Vehicle License Number
6e0
Signature of Hauler Date
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