HomeMy WebLinkAbout- Septic Pumping Slip - 76 ABBOTT STREET 6/6/2019 Commonwealth of Massachusetts
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City/Town of
IT
System Pumping Record
Form 4
INICA""'4,I
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DEP has provided this form for use by local Boards of Health. Other forms1 MVTW"'�'6V ut the
Information must be,substantially the same as that provided here. Before using this form, check with your
local Board of Hea]t I h to determIne,the form they usle.,The System Pumping Record must be submitted to
the local Board of Health or other,approving authority within 14 days korri the pumping date,in
accordance with 310 CM R 15.351.
All Fazi"Elty Information
Important:When I
filling out forms I System Locafion:
on the computer,
11
use only the tab
key to move your Address
cursor-do not
use the return ve-,
cit wn,
key'. V/To State T1 p—C--o—de—
2. System Owner:
Name
Address(if different from location)
City/Town
State Zip Code
3
Telephone Number
B,, Pumping Record
/ C)
1. Date of Purnping
Date 2. Quanfity Pumped: Gallons
3., Componentm El CessPool(s) [9 $0ept1c'Tank El, Tight Tank ED Grease Trap
El Other(descnibe):
4., Effluent Tee Filter present? [1, Ye r-1 No If yes,was it cleaned? El Yes El No
5. Observed condition of comporient pumped.
6. System Pumped By:
Name Vehicle License Number,
company
7. Location where contents,were disposed:
C/Cr
Signature of Ha6ler Date
Signature of Receiving Facility(or attach facilityreceipt), Date
t5form4.doc,*111/12 Systern Pumping Record page 1 of 1