HomeMy WebLinkAbout- Septic Pumping Slip - 60 RALEIGH TAVERN LANE 5/8/2019 Commonwealth of Massachusetts RECEIVED
City/Town
., System Pump*lng
Record
Form 4 V f II
DEP
f
.s provided this form for use by local Boards of Health. Other forms may be used but the, 1
information art be,substantiallythe earns as that provided here. Before uslingthis forml, check` ith your
local Board of'Healthto determine the form they use.The System Pumping Record must be submitted to
the local' card of Health or other approving authorifty,within 14 days frorn'the pumpingdate in
A. Facility Information
Important:
Men filling;out System Location:
fbrrns on the
computer,use
only the!tab key AddressP
to move your,
,cursor not
use the return CityfTown state Zip Code
Syste ' "
y
d'r s '(It different from location)
w
e
Elm--
City/Towh stag Zip Cod's
1
Telephone Number
B., Pumping Record
1. Date of PumpingDate
21. QuantVy Pumped:
Gallons
3. Type of system: Cesspool(s) 0 Septic Tank E3 Tight Tank ! Grease Trap
D-Other escH
. Effluent Tee Filter present? Yes 0 No If yes,was It cleaned?
5. Condition of System:
I
6. SysteJ**L.m Pump
Na e
Vehlde License Number
M4�
Com
pia
Location where,contents were disposed:
5
Date
Signature of Receiving FacAlity- Date
t5r . e System
Pumping Record Page 1 of I
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