HomeMy WebLinkAboutSeptic Pumping Slip - 110 OLYMPIC LANE 2/20/2018 err CoM' monwealth of Massachusetts µr t
� . yab City/Town
��t� P��14ORoardC��/ER, M,�. SAC�f�1S
.��� �� "�
- . 9 105
Form 4
z v°
DEB has provided this form for use by local Boards of Health. The System Bumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important: '
When filling out -1. system Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return Cityf]'own State Zip Code
key.
2. System/ owner:
Name
6- Address(if different frorn location)
—.— ------_..._._
Cityrl-own State Zip Code
Telephone Number
B. Pumping Record
1. Date of Purnping - - 2. Quantity Pumped:
Date Gallons
3 Type of system: ❑ Cesspool(s) _ septic Tank ] Tight Tank
❑ other(describe): --.....____ __ _ _.__,_._.....__.__.
4. Effluent Tee Filter present? ❑ Yes OXNo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:�
Name Vehicle t icense Number
Company
7. Location where contents were disposed:
Signa ure of Mauler Date
htt ://www mass. ov/de /water/a rovals�rms.litm#i .
p g p ,gyp nspect
I
l5form4.doc°06/03 system Pumping Record-Page 1 of 1