HomeMy WebLinkAboutSeptic Pumping Slip - 531 JOHNSON STREET 10/12/2017 Commonwealth �� Massachusetts
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System Pumping Record �� \
Form 4
ION
DEP has provided this form for use by local Boards of Health. Other fZ4%ay 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 ofHealth orother approving authority within 14days from the pumping date in
accordance with 310CK4R15.3b1.
A. Facility Information
Important:When
filling out forms 1, System LQcation.
onthe computer,
use only the tab
key tomove your /mumee
ovmnr do not
NorthAndov( r
use the return
key. City/Town s(a\v Zip Code
2. System Owner-
S6
Name
Address(if different from location)
City/Town State Zip Code
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B. Pumping Record
Quantity Pumped:
! Gallons
1. Date of Pumping Dat
3. Component: El Cesspool(s) SepticTank Tight Tank Grease Trap
Fl Other(describe): ------- `
4. Effluent Tee Filter present? El Yeo []-Iqb |fyes, was itcleaned? [l Ye
5' Observed condition of component�
8. Sd B /
Name / Vehicle License Number
Stev�rteSa ti 58GnK|mbaU8tBna�brd Ma
Company
7Location disposed:
so mill st b ford ma
ignature of Hauler
Signature vfReceiving Facility(or attach facility receipt) Date
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