HomeMy WebLinkAboutSeptic Pumping Slip - 7 Sullivan Commonwealth of.Massachusetts
City/Town of
System Pumping Record
� 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.
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A. Facility Information
Important:When �/�G+�.
filling out fomts I. System Location: Nov
on the computer,
use only the tab � \� S 2024
key to move your Address
cursor-do not
use the return
-key. .. - City/Town . ••A � state ' ��<'. Code -
� 2. System Owner:
EL
Name
Address(if different from location)
Citylrown State
. Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping S a ate 2. Quantity Pumped:
D
Gaitons
3. Component: ❑ Cesspool(s) ❑ Septic Tank
❑ Tight Tank El Grease Trap
❑ Other(describe):
4. . Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned?
❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
v
Company
7. Location where contents were disposed:
C�
Sign of Hauler I Date
Signature of Receiving Facility(or attach facility receipt) I Date
t5fom4.doc-11/12
System Pumping Record•Page 1 of 1
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