HomeMy WebLinkAboutSeptic Pumping Slip - 2050 SALEM STREET 7/19/2013 Commonwealth of Massachusetts
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City/Town of
System Pumping Record NORTH ANC�C�1/ � m °iiC�ff���aat����pp�"���rtttt����� ����✓t� '��mim «�Itdi{�c ,rv'4 PN i�lY���✓�I✓u✓Wiwi:
- Form 4 '
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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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key
Add ss
to move your
cursor-do riot ---�"" =— State _ Lip Cade
use the return CityfTown
key. 2. System Owner:
�° _ � >
Name _._.._.__.. _ __—.____._. __._..�— _
rte° Address(if different from lacatian)
City/TownState Zip od
Telephone Number
B. Pumping Record
1. bate of Pumping Date 2, Quantity Pumped: Ga116ns
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
I
6. System Pumped By:
Name `— -----___— Vehicle License Number
Company
7. Location where con io&ed:
g - — _._.�._ _..._ .Date
Signa
_.
. • ♦ p
$ tU
1 re of Receiving Facilit 1C1CQi� I°q pate
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