HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 217 GRAY STREET 11/7/2019 Commonwealth of Massachusetts RECENED
City/Town of 4+� A M pv o - NpV p l 2015
System Pumping Record .�00ofN0?'NPN�
r Form 4 N�LTM
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 your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1, System Location:
on the computer,
use only the tabt—
key to move your Address
cursor- et not �A �, V�Y p ,�r
key the return Cityrrown �� f _ G I S-44J
y
Zip Code
us
2. System Owner: State
Mlllur' t? I
Name
Address(If different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
p g Date 16 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? [5 Yes ❑ No If yes,was it cleaned? 01 Yes ❑ No
5. Observed condition of component pumped:
DCI
6. System Pumped By:
Name Service Pumping&Drain Co.,Inc. Vehicle License Number
5 Hallberg Paris
Company
7. Location where contents were disposed:
signature of auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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