HomeMy WebLinkAboutSeptic Pumping Slip - 100 TUCKER FARM ROAD 12/4/2017 ............
Commonwealth Of Massachusetts
City/Town of RECEIVED
9
Systsm Pumpoong Record
Form 4 ToWt,4 or-No�,j,�4 A�JWVFER
DEP has provided this form for use by local BoardsA�TH.t)Epp,r�,WENT
of Health. Other forms maybe used, but the
information Must be substantially the same as that provided here. Before using this form, check WithYour
local Board of Health to determine the form they use. The System Pumping Record Must be sub
the local Board of Health or other approving authority, mitted to
Important:
When filling out I. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not /(9
use the return Ity/Town
Ivey. State -------
2- System Owner; ZIP Code---
t .
Name
Address(if different from location)
Clt/Town
State ZIP Code--
-faiepnone Number
B.
Date Of Pumping 7
Date 2. Quantity Pumped:
Gallons---
3- Type of system: Cesspool(s) O'SeptIc Tank M Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? C] Yes No If Yes, was It cleaned? 0 Yes Na
5. Condition of System:
6. System Pumped By:
11JU1110
r') 2-eVehicle Ucensa—NU—m—b—er----------
Company
7. Location where contents were disposed:
Signature OvHauler Date
t6form4.doc-06/03
System Pumping Record Page I of I