HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 143 LACY STREET 9/3/2020 RECEIVED
S,\- Commonwealth of Massachusetts SEP 0 3 Szo
04 City/Town of Or l Ao6oVe-r lowrtofl4oW�M
_$ �
EW
Form 4
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 1. System Location:
forms the �C'U �)t
computer,
r,use J
only the tab key Address ��� O� ��
to move your (`'`1�V'
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
u
OI
Name
Address(if different from location)
City(rown State Zip Code
Telephone Number
B. Pumping Record ,
1. Date of Pumping ao t 2. Quantity Pumped: —�� (�
u
Date Gallons
3. Type of system: ❑ Cesspool(s) x Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: _
I ha coy)d On
6. System Poo)
Name'—�/ V9 r Vehicle License Number
Company
7. Location�r��tr�s were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1