HomeMy WebLinkAbout- Septic Pumping Slip - 147 JOHNNY CAKE STREET 11/15/2018 ~ '`
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Commonwealth of Massachusetts
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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 hena. Before using this form, check with your
local Board of Health tVdetermine the form they use. The System Pumping Record must be submitted to
the local Board of Health ur other approving authority within 14 days from the pumping date in
accordance with 31OCPNR15.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor'"°not '' An NN 01845
use Vme�m
hey. City/Town State Zip Code
2. System Owner:
Address(if different from location)
Name
|
City/Town State Zip CodeTelephone Nuhiber
|
B. Pumping� rd
/
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component F-1 Cesspool(s) [Q eotioTank [l Tight Tank Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? [l Yes 0�—f�n If yes, was it cleaned? [l Yes [l No
— Observed condition — component
-. -
Name VehicIo License Number
S 's Septic
Company
7 Location where contents ~e`disposed:
Signature of Receiving Facility(or attach facility receipt) Date
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