HomeMy WebLinkAbout- Septic Pumping Slip - 1063 SALEM STREET 12/12/2018 Commonwealth of Massachusetts
. City/Town of NORTH ANDC}V R dUtA ACHUSETTS
a _ a
- _ system Pumping Record i.± Form 4
1
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
Y
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use !� `��-
7Y1�'v�'+.
only the tab key address
to move your
cursor-do not I'v. ', ,4 r'
- ___..__ `__-
use the return City/Town ....
key. St<�te Iip_—Code_
2. System Owner-
Name `
address{if different from tacation}
.atate Zip Cade
Telephone Number
B. Pumping Record
1. Date of Pumping 3 ' _ ✓ ' 2
_—_.._._ Quantity Pumped:Data Gallons_
3. Type of system: [] Cesspool(s) [ Septic Tank ❑ Tight rank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑4 `�
'"No If yes,was it cleaned? (_] Yes No
5. Condition,-of System:
6. System Pumped By:
-1
Nara
Vehicle License Number
Compar7y
7. Location where contents were disposed:
c
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5fomA.docc 06/03
System Pumping Record•Page t of 1