HomeMy WebLinkAboutSeptic Pumping Slip - 333 RALEIGH TAVERN LANE 6/5/2017Commonwealth of Massachusetts
City/Town of
System 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.
A. Facility Information
Important:
When filling out 1. System Location:
computer, use 3 IS 3 Rci ) e
forms on the
only the tab key Address
to move your /V0 • i-) 0 el0 ye -I --
cursor - do not
use the return City/Town
key. 2. System Owner:
70 it
vern
State
Zip Code
Name
Address (if differentom location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
st "_ 3 / _
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: Cesspool(s) Septic Tank El Tight Tank
El Other (describe):
4. Effluent Tee Filter present? DI Yes, -No If yes, was it cleaned? El Yes 1:1 No
5. Condition of System:
/ 5&o
6. System Pumped By:
Name
c 7e c'
Company
7. Location where contents were disposed:
6_ S
Vehicle License Number
zgi
Signature of Hauler Date
t5form4.doc• 06/03
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