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System Pumping Record
lug 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: AUG 3 0 2012
When filling out 1. System Location: CITy OF S :\LSM
forms on the '///c. 4AD OF
computer,use 2/ V �4 l HEALTH
only the tab key Address
to move your fmil C7� 70
ret
cursor not ity own State Zip Code
use the return
key.
2. System Owner:
Name
Address(if different from location)
CityTTown State Zip Code
- W-i?- Y(3&6Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallon
3. Type of system: Lf/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 System::
6. System Pumped B :
�� �_� , 1998 Mack
amN a ', Vehicle License Number
Preventative Septic and Drain L.L.C.
Company
7. Location where contents were disposed:
Haverhill Waste Water Treatment Plant
Signature of Hauler Date
N/A
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
SERVICE 5 Hallberg Park WORK ORDER
North Reading, MA 01864
Pumping & Drain TOLL FREE: 800-794-9265
CO., INC. FAX: 978-276-0548 DATE: 1.-2/ 14f
WEB: www.servicepumping.com
ARRIVE:
"Protecting Your Environment for Over 80 Years" DEPART:
HOME PH:
PML: WORK/CELL PH:
NEW ❑ REPEAT
BILLTO: JOB NAME:
a \fail
_ PROBLEM: LOCATION: ❑ LEFT SIDE JOBTYPE: ❑ EMERGENCY
[]INSIDE ❑OUTSIDE ❑ FRONT FkREAR ❑ RIGHT SIDE IN/NEXTTO DRIVEWAY C}MAINTENANCE
SUB CONTRACT
QTY. WORK REQUESTED PRICE AMOUNT
❑GREASE TRAP IN/OUT gallons/lbs.
\VSEPTICTANK 0 `gallons r�
❑CESSPOOL Cgallons
❑ PUMP CHAMBER IN/OUT gallons
El SEWER MANHOLE IN/OUT 'rfgallons
El HOLDING TANK IN/OUT gallons
❑SAND TRAP IN/OUT '+U gallons
El STORM DRAIN IN/OUT L gallons
❑OTHER IN/OUTgallons
❑ DIGGING FT. IN.
❑TREATMENT: r�
❑ HIGH PRESSURE WATERJET
❑VIDEO PIPELINE INSPECTION
O TITLE V INSPECTION
P.O.#
TRUCK# TECHNICIAN HOURS RATS '1 AMOUNT TOTAL MATERIALS
CY TOTAL LABOR
*'- J TOTAL
Payment Method(circle one): CASH CHECK MC VISA AMEX BILL(TERMS:PLEASE PAY WITHIN 30 DLA/YS)
CREDIT CARD#: P. ;211k CODE ZIP bJ 9t6
G
k�
SIGNATURE: w _ Thank You
(I hereby acknowledge the satisfactory completion of the above described work.)
DELUXE FOR BUSINESS I-800-888-6327