HomeMy WebLinkAboutSeptic Pumping Slip - 58 SALEM STREET 1/19/2016 M", Cortlmanw� lt a as huse is
Ci#y/T own of
System um in Saar
r 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 forms 1. System Location
on the computer,
use only the tab
key to move your Address J b`#
�� � /} ♦.�
Cursor-do not f y)
use the return — d State 7_ip Cade
key.
CilyCfown
2, System Owner,
fyg O
Name
Warn .. ..__.....
/address(if different from location)
-..-_..__ - .....
State zi Code
City/Town
Telephone Number
B. Pumping Record
1. Elate of Pumping pate � , 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) t.1�" Septic Tank [] `fight Tank ❑ Grease Trap
❑ Other(describe): _
4. Effluent Tee Filter present? ❑ Yes-2 .No If yes, was It cleaned ❑ Yes R No
5. Condition of System
,E
6. System Pumped By
Vehicle License Number
Name
Company
7. Location where contents were disposed:
_._. .
date
Signature of Haule
.,__ — — bate
Signature of Receiv ng Facility
System Pumping Record•Page 1 0'
15form4.doc-03106