HomeMy WebLinkAboutSeptic Pumping Slip - 60 PATTON LANE 5/30/2017 Ccmmonweaft of M iad)usetts .
Clty frown of
System Pumping Record ,
Form 4
DEP has provided this loan 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:
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w 2. System owner.
Name
Address k"o" "M f om location)
CNy/ToMm
State t-. Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date� 2. Quantity Pumped
Gallons
3. Component: ❑ Casspool(s) ❑"Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter preseW ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Systepm Pumped By:
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r < ` VehPcde Ucense Numbar
7. Location where contents were disposed:
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Signature of Haubr
Date
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