HomeMy WebLinkAboutSeptic Pumping Slip - 76 ABBOTT STREET 5/3/2017Commonwealth of Massachuse
City/Town of
Syste 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.
R.L.L';;E:IVED
A. Facility Information
Important:
When filling out
1. System Location:
forms on the
computer, use '\--1"" 4
only the tab key Address
to move your
cursor - do not
use the return City/Town
key.
2. System Owner:
Name
State Zip Code
Address (If different from location)
City/Town
Pumping Record
State
Telephone Number
Zip Code
77
(
Date
Gallons
3, Type of system: El Cesspool(s) -Septic Tank 1p Tight Tank
E] Other (describe):
1. Date of Pumping
4. Effluent Tee Filter present? El Yes la -No
5. Condition of System:
2. Quantity Pumped:
If yes, was it cleaned? El Yes EI No
6. System Pumped By:
Name
130 rca' ,ze k:S
Company
7. Location where contents were disposed:
Vehicle License Number
6 ec
Signature of auler
Date
t5form4.doc• 06/03
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