HomeMy WebLinkAboutSeptic Pumping Slip - 45 BRIDGES LANE 5/3/2017Commonwealth of Massachuse
City/Town of
System Pump i g Record
Form 4
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DEP has provided this form for use by local Board';:H'elthc.Other ;L: may be used, but the
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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
Important;
When filling out 1. System Location:
forms on the
computer, use
only the tab key Address
to move your
cursor - do not
use the return City/Town
key.
No o 610 Ve 11/26
2. System Owner:
(,57")1,5i (.5.?
Name
Address (if different from location)
City/Town
State
Zip Code
Pumping Record
1. Date of Pumping
3. Type of system: Cesspool(s) D Septic Tank
D Other (describe):
State
Telephone Number
Zip Code
(:( 3
/9 /
Date
4. Effluent Tee Filter present? Ei
5. Condition of System:
2. Quantity Pumped:
Gallons
Ej Tight Tank
If yes, was it cleaned? 0 Yes El No
6. System Pumped By:
Name
Company
7. Location where contents were disposed:
Vehicle License Number
Signature of Hauler
Date
t5form4.doc• 06/03
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