HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 OLYMPIC LANE 10/3/2019 Commonwealth of Massachusetts
City/Town of RE�EIVED
S�� 'm Pumping Record OCR 0 3 �p19
Form 4
ZH ANDC�R
DEP has provided this form for use by local Boards of Health. Other f 10�NN DF NOR �PTMENt
information must be substantially the same as that provided here. Before using this y be-Used, but the
local Board of Health to determine the form they use.The System Pumping Record must be sulbmitt dot0
r
the local Board of Health or other approving authority.
Important
When filling oui 1- S9stern CBcafion:
forms on the •• ''
`;t ,
computer,use �6
only the tab key Address Olk
to mavb- our
cursor-do not
use the return City/Town _
Ivey State Zip Code 2. System Owner;
r //
Name �1 -e`
rrtra ' c Address(if different from lacatton)
CitylTown
state Zip Code
Telephone Number
a. Pump sec®a�e8
I. Date of Pumping 30-/
Date 2. Quantity Pumped;
Gallons
3. Type of system: ❑ Cesspool(s) ❑ueptic Tank
❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System: a.
6. System Pumped By: �
Name Vehicle License Number
Company
7. Location where contents were disposed:
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G Pvrz�-/�
Signature or mauler Date
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