HomeMy WebLinkAbout- Septic Pumping Slip - 337 HILLSIDE ROAD 6/24/2019 I
«.
yyyyyy��ppyy�r �,; JJ
i
Ith of Massachuseffs
Commonwea
Uty/Town of
m
e System
ry
Fonn 4
DEP has provided thls form for use;,by local Boards of-Health. Other formt may bebsed, but the
information,must be
l using.this ;, with your,
I o c'l Boa,rd,of Health to determine the forM. they use.The$ystem Pumping Record must be S
the local lth or other approving
As Factility Inform' aflon
-ou
. System Loca front of house, Left Right,rear f us. *.. fig s!_e
d
fight side i �, e fi bl l fight rear Cif it l, ' '�
1
Address�
Cityrrown to Zip code
2. System Owner:
* f
J
Address Of different from location)
Ci ' State'
r i
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2,. Qu6ntity Pumped: Gallo
ns
p
3.
y l " E0,900fic Tank TightT
El Other(describe):
4. Effluent ,ele FilterYes 0 I l Yes E] No
5. Condition,o
1
6., System Pumped
y
i
Nell.
Narne Vehicle License Number
Batesion E "" w I
Company
art .
M.S.
wDate
a
t Pumping r