HomeMy WebLinkAbout- Septic Pumping Slip - 15 WINTERGREEN DRIVE 10/16/2018 Oommonwealth of Massachusetts
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Y t u pin Record
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Form 4
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 yo
local Board of Health to determine the form they use.The System Pumping Record must be submitted
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.361.
A. Facility Information
.Mrs -'
ro4ma 1. . Sjjystem Location:
,twy'o me"Your Addre
ousor,r(a no
tale S
k Zip Code
2. System Owner
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( ftom 4C&tlen)
ovm State Zip Cade
d LS
Telephone Number
IS. PumpingRecord
Data
1. Date of Pumping ---- 2. Quantity Pumped:
s3elfona ,
3: Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? ❑ 'Yes ❑ No If yes,was it cleaned?
❑•Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
. , l
Name
vehicle MORN Number
Compagy .
7. Location�wsre contents were disposed:
Signature of Na
Date
Signature W Recetvtng FacW4f(or attach faciAt mmc,mpt) Data