HomeMy WebLinkAboutSeptic Pumping Slip - 1635 OSGOOD STREET 1/9/2018 Commonwealth of Massachusetts
A City/Town of d;
System Pumping Record
Form 4
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, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, I`
use only the tab
key to move your Address
cursor-do not f
use the return Ci JTown ( ✓� �y
key. ty State Zip Code
_ ur
2. System Owner:
Name
raa "
Address(if different from location)
CitylTown Stale Zip Code
Telephone Number
B. Pumping Record
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1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 0/-Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Ok ;SdL
Name J Vehicle License Number
Company
7. Location where contents were disposed:
l `n
V
LJ-7
Signature of Haul Date
Signature of Receiving f=acility(or attach facility receipt) Date
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