HomeMy WebLinkAboutSeptic Pumping Slip - 357 CANDLESTICK ROAD 5/2/2018 COMMonwealth Of Massachusetts RECEIVED
City/Town of
MAY 0 2
Syst8m PUMPUIng Record
Form 4 XWN OF NORTH AMWER
IiEAUM DEPARIVENT
DEP has provided this form for use by local Boards of Health. Other forms mabe usedbut the
,
Information Must be substantially the same as that provided here. Before usingy 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.
F�ac 1111�yl n I�or m a�fi o�n
Important;
When Ming out System Location,- 24
forms on the
computer,use
only the tab key Address
to Move your
cursor-do not
use the return -1w I uwn
key. State
2. System Owner: ZIP C—ode—, ---
yl ol
Name
Address if dIfferent from location)
CV-TTown
State ZIP Code--
'telephone Number
P-dm�pin�gft�cord���
/ '7-
Date Of Pumping
Uate2. Quantity Pumped:
3. Type of system: n Cesspool(s Gallons ---
Septic tar Tight Tank
C3 Other(describe):
4. Effluent Tee Filter Present? n yes,
If yes, was It cleaned? Yes No
5. Condition of System:
6. System Pumped By:
Name
112 ,�r Vehicle License
Number 'I
Ze k
Company
7. Location where,contents were disposed:
s
Signature or Hauler -------------
Date
t6form4.doc-06103
System PUMPInq Records Page I of I