HomeMy WebLinkAboutSeptic Pumping Slip - 1049 SALEM STREET 12/9/2015 use a rr r rye a�m rar r r rem r r4�
City/Town
System' Pumping Record
Form 4
CEP has provided this form for use by local Boards of Health-.Other forms may be used, but the I
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$ys Purnpin R r)d� 16 ", .fled to I
the lord Board of(Health or other Approving authority within 14'days it 111% In
accordance with 310 CMR 15.359.
A. Facility Informati®n
Important:when
filling out forms 1. System Location:
on the computer, , ,am
use only the tab
key to move your Address -
cursor o do not f
use the return 01/�i., f Yt r��(� V .-
key Cityfrown State Zip Code ".
2. System Owner:
Name --
Address(d different from location)
cityfrown State' Zip Code
Telephone Number
B. Pumping Record
1. Cate of Pumping pate 2. quantity Pumped: '' 000
Gallons
3. Type of system: El cesspool(s) Septic Tank Tight Tank (j Grease Trap
El Other(describe): h /
4. Effluent Tee Filter present? El Yes 'No If y0s,was it cleaned? El Yes No
5. Condition of System:
s. System Pumped By:
Name Vehicle License Number
Company
7. Location wher4 contents were disposed:
Signature of Hauler pate
Signature of Receiving Facility pat®
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