HomeMy WebLinkAboutSeptic Pumping Slip - 160 BOSTON STREET 9/11/2017 Commonwealth of Massachusetts
Cita/Town of AVERCUSETT
System Pumping Record
Form 4
(SEP has provided this form for use by local Boards of Health. 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: "
on the
forms
f �
computer,use
only the tab key Address
to move your
cursor-do riot
use the return City/Town State Zip Code
key. '
2. System owner
r amt /
i
e
rev Address(if different from location)
City[Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Gallons 2. Quantity Pumped: ......
3. Type of system: ❑ Cesspool(s) MSeptic Tank Tight Tank
❑ other(describe):
4. Effluent Tee Filter present? ❑ Yes [= No If yes,was it cleaned? [] Yes ❑ No
5. Condition of Syst/e`�:
6. System Pumped By:
_511141- 7—/C
Name Vehicle License Number -_....._ _...,....
I
Company
7. Location where contents were disposed:
Signature of Hauler pate
http://www.mass.gov/dep/water/approvals forrns.htm#inspect
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