HomeMy WebLinkAboutSeptic Pumping Slip - 226 REA STREET 1/9/2018 Commonwealth Of Massachusetts
City/Town of
Syst(Dm PumPlng Record
Form 4
DEP has Provided this form for use by local Boards of Health. Other forms may be u
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.
Important;
When filling out 1. SYStarn Location-,
forms on the
computer,use
only the tab key Address
to Move your
cursor-do not
�Ll'
use the return TIR—Tow—n
key. State ------
System Owner:
2. ZIP Cade----------
QYV.ZYA�- Address(if different
State
-ZIP Code---'
Telephone Number
B.-Pu pj�ng R�Gcor� � -
7
1. Date Of Pumping
-bate 2. Quantity Pumped.
3- Type of system: n Cesspool(s) " 'P Gallon—s ----
t I c Tank k Tight Tank
❑ Other(describe):
4. Effluent Tee Filter Present? ❑ Yes No If Yes, Was It cleaned?
Yes ❑ No
8. Condition of System:
6. System Pumped By:
Name
0 Vehicle License N-U-M-b--e-r------------------------
Company r&,C.2-0 k 5!;a V�it
7. Location where contents were disposed:
SIgLhazure urnauier
Date
t5fbrm4,doc#06/03
System Pumping Record-Page 1 of 1