HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 288 STILES STREET 5/8/2020 Commonwealth of Massachusetts R
City/ "own of
MAY 8 2020
Forte 4 Mping Record
DEP has provided this form for use by local Boards of Health. Other forms may
b
information must be substantially the same as that provided here. Before using this form
Y e used, but the
local Board of Health to determine the form they use. The System Pumping Record must
the local Board of Health or other approvingcheck with your
authority. be submitted to
A. �acali$y end®rllvaat�®�a
Important:
When filling out t. System Location:
forms on the
computer,use
.only the tab key Address
to move?our
cursor-do not
use the return Clty/Town /1 r G��`' '� 1�3'!G
key. St at
e
2• SYStem OWneC; ZiP Code
ctf. Name ��t I l 7 ��•�
Address if d%
( rentfrom location)
City/Town
State 70c
c26 Zip Code
Telephone Number 6` r 3
B. P�ping Recor
1. Date of Pumping 3 -- i3--2C) l So
Date 2. Quantity Pumped:
3. Type of system: ,�,� Gallons
❑ Cesspool(s) L� Septic Tank •
❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned?
❑
5. Condition of System: ti ❑ Yes No
6. System Pumped By: r
Name
Vehicle License Number
2-C 1cS S� 41t
Company
7. Location where contents were disposed:
6i L Y, P
6 G�•y�
Slgnature of Hauler
Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 1
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