HomeMy WebLinkAboutSeptic Pumping Slip - 1001 JOHNSON STREET 6/6/2018 Commonwealth Of Massachusetts
City/Town of 4 "Ch
System PUMPIng Record
Form 4 �04?v 0
�*,
Z,14
DEP has provided this form far use by local Boards of Health. Other forms ma be ' 1110i,1'11�4'1
information must be substantially the sameY used, 6
local Board of Health to determine as that Provided here. Before using this
rmine the form they use.The System form, check It Your
the local Board of Health or other approving authority. Pumping Record must be submitted to
A. Facility Wormatlon
Important;
When filling out I- System Location-,
forms on the
computer,use
Only the tab key Address
to move your 4-
cursor-do not
use the return Wrown
-22
Icey. 2. State -------
00 System Owner: —ZIP Code
Name /1 'S,'o C",
Law 19 Address�(if djff�erent from
Address 1 lffe ant from location)
CIVWTOW"n
State
ZIP Code
--
Telephone Number
-§—P�UMp�fng�Reco�rd
I. Date of Pumping
-5a*t`e---1 2. Quantity Pumped:
3- TYPO Of system: Dations
n Cesspool(s)
[D" Septic Tank n Tight Tank
❑ Other(describe);
4. Effluent Tee Filter Present? E] Yes
5. Condition of System: No If Yes, Was It cleaned? ❑ Yes 13 No
6. System Pumped By:
Vehicle—Umnae—Number
CompanA2-IJCA� 1<S
7. Location where contents were disposed:
s, D
019(IR(Ure OT Hauler
Date
t5form4.doc-06103
System Pumping Record-page I of 1