HomeMy WebLinkAboutSeptic Pumping Slip - 557 BOXFORD STREET 3/9/2018 Commonwealth of Massachusetts
City/Town of
System Pumping Record AU G 1, 3 20 8
Form 4
t
DEP has provided this form for use by local Boards of Health. Other forms ma`y!66"6sk,.b the
inforrnation 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.
A. Facility Information
Important:
When filling out 1. System Location,
forms on the
computer,use
only the tab key
to move your
cursor-do not Cityfrown State Zip Code
use the return
key.
2, System Omer:
Name
Address(if different from location)
--—-- --
City/Town Zip Code ----------
Telephone Number
B. Pumping Record
1. Date of Pumping oofe2, Quantity Pumped: -Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes r�o If yes,was it cleaned? n Yes El No
5. CondWon of, ys em:
r
6. Sys m Pulped By:
Vehicle License Number
Company
7. Loc Mt* whqCco n7t
tspqre disposed:
V
_Sign;ew��LA Date
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