HomeMy WebLinkAbout- Septic Pumping Slip - 1190 SALEM STREET 5/8/2020 Commonwealth of Massachusetts
City/ 'own of D
SY3tGm Pumping RecordMAY
Form 4 i
DEP has provided this form for use by local Boards of
Health, Other information must be substantially the same as that Provided ere. Before forms may be used, but the
local Board of Health to determine the form they use. The System Pumping
the local Board of Health or other approving a using this form, check with your
PP g authority.
y P g Record must be submitted to
A. �clfty 6n�®�mafi®�a
Important:
When filling out I. System Location:
forms on the l
computer,use
.only the tab key Address
to move-?Our
cursor- not use the return
key. p State
— 2 System Owner: Zip Code
r rcb
c � Name ✓�
rrtm ''�f Address(if different from location
City/Town
Spate Zip Code
07 _
Telephone Number
1. Date of pumping Y-:�O—�2o
Date 2. Quantity Pumped: _____l_U J,J
3. Type of system: Gallons
❑ Cesspool(s) ❑ Septic Tank Tight Tank
❑
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �o If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System:6. System Pumped By:
Name
0� < �e fCS Vehicle License Number
Company S C� ��C
7. Location where contents were disposed:
Signature of Hauler
Date
t5form4.doc•06103
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