HomeMy WebLinkAboutSeptic Pumping Slip - 71 LIBERTY STREET 6/6/2018 omrnonwealth of Massae
Cityl`�own of Massachusetts
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system Pump-rig Re(cored erg,/V
Form 4
DEP has Provided this farm for use by local Boards of Health. Other forms may be use �
information must be substantially the same as thafProvided � R� � �
loco( Board of Health to determine the form they use.The System Pum ' d: bine
here.Before using this form, check with your
the local Board of Health or other approving authority. ping Record
must be Submitted to
�o Facility infoImportant;
When filling nut 7_ Sy�E®m Location:
forms on the
computer,use
only the tab trey 7Address C r ^: `...
to move your
cursor-do not �O
use the return Town
Ivey.
2. System Owner: Sia#e Zl—PC-0 de
,e
oke
rntn Address 0fdift'erentfrom location)
C, Town
State
ZIP Code
TelephoneNumber
'(. Date of Pumping
Date 2. Quantity Pumped:
3- Type of system: Gallons
a Cesspool
(s) [ pile Tonic
Q Tight Tank
�] Other(describe):
4. Effluent Tee Filter present? C] Yes o If yes,was It cleaned
Yes � q,,tt)
S. Condition of System: ,
,p), ,,.
6. System Pumped By: 4�
Name r
('2,.P- fc S S eo e4i G Vehlole L tcense Number
Company j
7. Location where contents were disposed: i
Signature of Hauler ---"'"' gate
0=4.doca 06/03
system Pumping Record a Page i of