HomeMy WebLinkAboutSeptic Pumping Slip - 76 OLYMPIC LANE 11/3/2017 Commonwealth Of Massachusetts Rr-',CEIVED
City/Town of
SYst8m Pumping Record
Form 4 moqT
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, the ck with your
local Board of Health to determine the form they use. The System Pumping Record must
the local Board of Health or other approving authority, be submitted to
A. —Fa�clflty
on
important;
When filling out I. System Location:
forms on the
computer,use
only the tab key Address yl
to move your
cursor-do not L7
ii7------------- --------z
use the return City- .......
key. State
2. System Owner: ZIP Code-----
c
Address tlf different from Iocation)
Cfty�f,OW,
State Zlp Code
— I
Telephone Number ------
B. dumping Record
I. Date Of Pumping 3
Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s)
Septic Tank M Tight Tank
El Other(describe):
4. Effluent Tee Filter present? EDYes If Yes, was It cleaned? 0 Yes No
5. Condition of System:
13. System Pumped By:
Name
Vehicle License Number
Company
7. Location where contents were disposed:
Signature ot'Hauler
Date
t5form4.doc-06/03
System Pumping Record Page 9 of 1