HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 217 GRAY STREET 3/18/2020 Commonwealth of Massachusetts,
City/Town Of-
System Plumping ecor+
nForm 4 , .. "
CEP 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 clays from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:"v an
filling cut forma 1. System Location:
on the computer,
use only ft tat ..
tKey to,move your F4rem�� ��.........---- �_.,......_____.
.,
cursor-do not
use the return CitydToSlate tiwn
Zip Cate
'. System Owner:
�Sddreea $f dtrf�erent ftrrm locaiwora, ....___
CityrfowV _..._
State Z
Arta Code
TaOephone Number
B. Pumping Record
1. Date of lumping
as . Quantity pumped;
Gallons
3 Component: Cesspool(s) Septic Tank Tight Tanik
g Grease Trap
® tither(describe);
4. Effluent Tee Filter present? 0 Yes No If yes,was It cleaned? El yes
El No
. Observed condition of component pumped:
5. System pumped By:
Name Vehicle License Number
crt ir�Uj�npn"c
Company ertllttlHa4�trttti,�ttu�
7. Location'where contents were 8ijpf,siidd:
Date
Signature of tieceron'Facility
g or aCiach facGuti+receupt� C7ate ry°�—
t5form4.doc•11/12
System humping Record w gage 1 o'f 1