HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 220 BOSTON STREET 10/3/2019 ` Commonwealth of Massachusetts
y. City/Town of
.� SY-st'sm Pumping Ric®rrd oc10 3 'Lo19
OVER
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms y?h�:iPl OF ;`RZMEN�
information must be substantially the same as that provided here. Before usingthis Used, but the
local Board of Health to determine the form they use.The System Pumping Record mum' check with your
the local Board of Health or other approving authority_
must be submitted to
Aa �ac1r y l>�al®Irmatio>la
Important
When niling out' 1- System C66ation;
forms on the
computer,use /?
only the tab key Address
to move`�our
cursor-do not
use the return Cttyll own
Ivey. State Zip Code 2. System Owner;
,� I
Name S�1 �C%, L. � r�,r c,1
Address{if different{rom Iocailon)
City/Town
State
Z)p Code
Telephone Number
Se PlUmpling Record
1. Date of Pumping
Date 2. Quantity Pumped: ---
Gallons
3. Type of system: ❑ Cesspool(s) EaSe tic Tank
p Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes R No If yes, was It cleaned?
Yes No
5. Condition of System: a.
zvvc�
6. System Pumped By;
Name Vehicle License Number
�� ZE IcS SC : c
Comp na y
7. Location where contents were disposed:
� LS1�
signature or Hauler Date
t5form4.doc-06/03 -
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