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HomeMy WebLinkAboutSeptic Pumping Slip - 120 CRICKET LANE 1/9/2018 COMmonwealth Of Massachusetts A City/Town of SYstsm PUmping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms information must be-substantially the Sam ay be used, but the e 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 sub the local Board of Health or other approving authority» mitted to important; K—Fa�cll ly When filling out I. System Location: forms on the computer,use 41 Z" only the tab key Address to move your r,ursor-do not use the return City/I own key. State ZIP Code 2. --- System Owner: Name rertan y' Address(if d6fferrnt fr©m location) CTII—To—wn Stets ZIP co—de— Telephone Number—-- Pum�ping�Rec�ord 7 Date of Pumping J 2. QuantitYPumped: Gallons flats 3. Type of system: Cess pool(,q) 'Septic TatK) ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter Present? ❑ Yes 0 No If Yes, was It cleaned? ❑ Yes No 5. Condition of System: 6, System Pumped By: Name 0 Vehicle License a Niri 1113er------- ' Q-CCAJC'—Ze k Zomi.:Iany 7. Location where contents were disposed: S signature of Hauler Date t5Forrn4,doc-06/03 System Pumping Record 4 Page 9 of I