HomeMy WebLinkAboutSeptic Pumping Slip - 720 FOSTER STREET 1/9/2018 Commonwealth of Massachusetts
City/Town of
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,
use only the tab t
key to move yourcurMRn
use the
ret not AAA—
use the return Ci !Yawn �J 1 J (G
key. City/Town (State Zip Cade
2. System Owner:
.e&eel
Name
atm
Address(if different from location)
CItylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �! p 2. QuantityPumped:
DateGallons
3. Component: ❑ Cesspool(s) 53-Iseptic 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:
€1 �, s,
ds—
Name Vehicle License Number
4 w DoX
Company
7. Location where contents were disposed:
� � � Ji
Signature of HaulDate
Signature of Recelving Facility(or attach facility receipt) Date
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