HomeMy WebLinkAboutMiscellaneous - 165 INGALLS STREET 4/30/2018 (7) Commonwealth of Massachusetts
City/Town of
System Pumping Reco d RECEIVED .,,
Form 4
NOV 14 2007
DEP has provided this form for use by I I Boards of Health. Oth forms may be used, but the
information must be substantially the I? afore using this form,check with your
local Board of Health to determine the fV umping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. SySt m LOC � —
fonT*onthe
computer,use l
only the tab key Address �1 /) /' moi✓
to move your �'V
cursor- ,not
use the r6tu'm Cityrrown State Zip Code
et
key. 2. System Owner:
Name
Address(if different from location)
City./Town State
Telephone Number C�
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
I
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of Sys�te���
6. System P m �j�y:
! Name Vehicle License Number
I
Company
i
7. Location re conte4
ver posed:
Signaller Date
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