HomeMy WebLinkAboutSeptic Pumping Slip - 1001 JOHNSON STREET 6/5/2017 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 0\:,
DEP has provided this form for use by local Boards of Health. Other forms maybe 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:
forms on the
computer,use
only the tab key Address
to move your silo A oA6 v e-�---
cursor-do not
use the return Cityfrown State Zip Code
key. 2. System Owner:
04 a L
Name
Address(if different from location)
CityfTown State Zip Code
-3Mfr c/
-Telephone Number
B. Pumping Record
6--'6z) 7 00
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? n Yes n�No If yes,was it cleaned? ❑ Yes ❑ No
6. Condition of System:
6, System Pumped By:
Name Vehicle License Number
ZL
Company
7. Location where'contents were disposed:
—6
Signature ofHauler Date
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