HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 SUMMER STREET 9/3/2020 RECEIVED
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System Pumping Record HEALTH DEPAMENT
/! 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 on the
computer,useonly the
cursor-d b key Address �� _ _ ��, 5
to move your t`��
cursor-do not
use the return City/Town State Zip Code
key' 2. System Owner:
�Q aaff ti1a�
Name
'fD Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date'`—i—I 2. Quantity Pumped: GallonsO
3. Type of system: ❑ Cesspool(s) [ 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 Syste
6. System Pumped By:
Yt,
Name
am Vehicle license Number
WfCompany �
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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