HomeMy WebLinkAboutSeptic Pumping Slip - 465 BOXFORD STREET 9/11/2017 4 Commonwealth of Massachusetts
- - City/Town of NORTH
N =°X System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping R d must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important: t
When tilling out 1. System Location: Dgpp
forms on the ----
computer,use .E1..� ........... �....._
1 a fL„
only the tab key Address
to move your JL)
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
VQ b-V— 47-1r
Name
Address(if different from location) 1
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - A _ . ____- 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): _ _______.. ._...__ ._........ ............ .
4. Effluent Tee Filter present? ❑ Yes [allo If yes, was it cleaned? [l Yes ❑ No
5. Condition of System:
tw: �
6. System Pumped By:
Name Vehicle License Number
Company —-
1
7. Location where contents were disposed
Sig i e of Hat er Date
http://www.mass.gov/dep/water/approva /t forms.htm#inspect
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