HomeMy WebLinkAboutSeptic Pumping Slip - 315 SOUTH BRADFORD STREET 1/1/2008 Commonwealth^�
City/��' r��
Town`�vv/ / ��/
System Pumping �������� - _�� ~~� �
Form 4
DEP has provided this form for use by local Boards of Health. Other
information must ba substantially the same as that provided here. Before using this fo |, 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 CyNR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms onthe
only the tab key Address�� �\n
oursor-donot � ' |
use the return °"y 'o=' State Zip Code
key. �
2. System Owner: �
V �
���
�
Address(if different from location)
—Telephone Number
B. Pumping Record
�� �� / r1
1. Quantity `/
ofPumping 2� Quantity Pumped: Gallons
3. Type ofsystem: [] Cesspool(s) R SepboTank f-1 Tight Tank Fl Grease Trap
Fl Other (describe):
4. Effluent Tee Filter present? Fl Yes No |f yes, was itcleaned? n Yes [l No
5. Condition of System: �
O. System Pumped By:
Company
7. Location where contents were disposed:
�� � ��
��°m=,����^��
\
�
'
Signature of Receiving Facility Date
mfonn4doc 0300' System Pumping Record'Page 1o/I
Commonwealth of assac usetts
City/Town of
System Pumping ecor
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 1. System Location: y
forms on the
computer, use )I , ` `a -W_
only the tab key Addlre s ``__� //�� ,�✓ //°°�� /� .»°
to move your o C `t i �° 0( 7� \
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
ATM
e�
1. Date of Pumping Date y Pumped: Gallons
3, Type of system: El CesspooS T Tight Tank El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
co ;�C�C�
6. System Pumped By:
J1`yw�v 1 t �1 .. > 'f
N me Vehicle License Number
1Y� �.� i'VC.�� f1V1 Y1YYley)" CA
Company
7. Location where contents were disposed:
°ignaW e of 'aCiler Date
Signature of Receiving Facility Date
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