HomeMy WebLinkAboutSeptic Pumping Slip - 517 JOHNSON STREET 3/15/2016 ommw� a i`f w.
i
Commonwealth Of Massachusetts
City/Town Of �' ,)
System Pumping Record HEAL"mDEPAR]" ENT
Facility Information-
System Location:
Address
City/Town State Zip Code
System Owner:
Name:
Adress (if different from location of pump)
City/Town State Zip Cade
Telephone Number
Pumping Record
.W
Date of Pumping Quantity Pumped gallons
Type of System � Septic Tank _Grease Trap Other _(what)
System Pumped b
Company: ROOTED-MAN 1.2 East Dracut Rd., Methuen, MA 01844
"l
Location where contents were disposed:
Signature of Hauler � Date
Coo-j i nonw alth of Massachusetts
C,�hvjown of � a:., ( 14
System eo rd H ASV
Pumping
q
DFP has provided this form for use
the samelas that provided here. Before using his form,check with your
information must be substantially Record must be submitted to The System
coca;Board of Health to determine the fo tauthasr�ty within 14 day from the pumping date in
the local Board of Health or other approving
accordance with 310 CMR 15.351.
A, Facility information
importanik -y stem
when filiinC out '
forms on the myLoca� � f
to �V.." IA ,.. _._ ..
computer,use _-.. z
only the tad key Address j
�•„ {� Code
to move you _ State
cursor-do not City(Town
use;tie return
key - m Own r
� system
Name
Address(if different from location)
Zip Code
Skate
CityiTown
jT e g
p r —
pumping Record
`' Gallons
Date of Pumping Date : � � � — 2' Quantity Pumped. _
Tight Tank ❑ Grease Trap
J.
Type of system: ❑ Cesspool(s) Septic Tank ❑ 9
(] Other (describe): -
Flo if yes, was it cleaned? ❑ yes ❑ No
a, Effluent Tee Filter present. Yes❑ �,
5. Condition of System:
y
5. System P umped By:
0
_„ __ hiCle License
Name L � o
Company
i. Location where contents were disposed:
. , .... _ Date
Signature of Hauler
Date
Signature of Receiving Facility
System Pumping Record Page t of f
15farm4doc 03!06