HomeMy WebLinkAboutSeptic Pumping Slip - 93 CRICKET LANE 3/5/2018 Commonwealth Of Massachusetts
City/Town of �CEIVED
A SY-Stsm Pumping Record �016
Form 4
ANOV�'R
TOWN or�NORTI o
KALJ�4 DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other fo`M8 may be used, but the
information Must be substantially the same as that provided here.Other
sin thisform, check with your
the local Board of Health or other approving The System Pump u Record
g co
local Board of Health to determine the form they use. Pumping \e rd Must be
g authority, submitted to
lnf
Important; c�)rma�tjon
When Ring out 1- System Location;
forms on the
computer,use
only the tab key Andress
to move your
cursor-do not
use the return Cli7/_Town /�' L
Ivey. State
2- System Owner: ZIP C—cde----
Name
Address(if different from iocatian}
C1V/_T0_Wn_________________ State ZIP Code
2
Telephone Number
B. umping
1. Date of Pumping Date 2. Quantity Pumped,
Gallons
3- Type of system: Cesspool
(s) D Septic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter Present? Yes No If yes,was It cleaned? C1 Yes n Na
5. Condition of System.-
6. System Pumped By:
Name
C) k� Vehicle License Number
7�
Company
7. Location where contents were disposed:
bignature OT muser Date
t5fbrm4.doc*06/03
System Pumping Record Page I of 1