HomeMy WebLinkAboutSeptic Pumping Slip - 27 BOXFORD STREET 7/30/2018 Commonwealth of M ssachusetts RECEIVED
Cit, y/Town of jul- 302018
I System Pumping Record Tovvt4()r� MJ)OVER
Form 4 11EALflI DU'AIUMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information 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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return -1
h
key. Cltyrrovyn State Zip Code
2. System Owner:
Name j
Address(if different from location)
Zlijffown 7State Zip Code
) I'
Telephone Number
B. Pumping Record
1. Date of Pumping Date 1 2. Quantity Pumped: Gallohs
3. Component: El Cesspool(s) U/Septic Tank M Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? n Yes ❑ No If yes,was it cleaned? F-1 Yes E] No
5. Observed condition of component pumped:
6. System Pumped By:
—Lb C" � I a cau—
Name j Vehicle License Number
I dz*g.�
Company
7. Location where contents were disposed:
Date
Signature of HauI95
Signature of Receiving Facility(or attach facility receipt) -Ca—te --
t5fornA.doc-11/12 -.4,
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