HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2177 TURNPIKE STREET 9/25/2019 Ike
� CommonwealthSFp
of Massachusetts r°�o�N
City/Town of_LLB A h d GIVE rti �Rry,� 9
System Pumping Record ` 'ilt_z f
r 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 here. Before using this form, check with our
local Board of Health to determine the form they use. The System Pumping Record must be submltte
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.351. d to
A, Facility Information
Important;When
filling out forms I. System Location:
on the computer,
use only the tab 2
117
key to move your Address t
cursor-do not /�
use the return 4C "\
key. Clty/7own
State 2. System Owner: Zip Code
Name
fit' �) Qifl I(' P
Address(If different from location)
City/Town
State Zip Code
B. Pumping Record Telephone Number
1. Date of Pumping
Date 2. Quantity Pumped: I()
Gallons
3. Component: ❑ cesspool($) Septic Tank
/\ ❑ Tight Tank El Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
If yes,was It cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name -
Smice Pumping&Drain Co..mc. Vehicle License Number
Company North Reading,MA 01864
7. Location where contents were disposed:
?Siqnatuof.Hau dr
Data
SlUnaturo of Receiving Facility(or attach facility receipt) Dete
t5form4.doc•11112
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