HomeMy WebLinkAboutSeptic Pumping Slip - 1476 SALEM STREET 3/24/2016 Commonwealth of Massachusetts d=orm 4--System pumping Record'
Massachusetts
System Pumping Record r UK"i
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System Owner System Location
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Type: Emergent Routine
Cesspool: No Yes Septic Tank: No Yes - "
bate of pumping: Quantity pumped: Gallons
System pumped By: Wind River Environmental,LLC permit :
Contents Transferred to:
v.) l}r. V'..oQ 4b'MwT II
St
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G.a," ti 374-2382
Contents bisposed at:
bate: pumper Signature; µ "
Condition of System/Other Comments
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k"rLrtedear�rwcyt.Irti�rd�pe.r bep Approved Farm- 12/07/95
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Commonwealth of Massachusetts
City/Town o „Etr °ail
f
- y to Pumping Gory
Form 4
DEP has provided this form fQ•r 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:
forms on the )
computer,use _ _.)_ � /. C,.. _
only the tab key Address ,r
to move your -/fC � ��t!°
cursor-do not __.... .�`� -6 City/Town State P Code
use the return
--
key. 2. System Owne
Name
�« Address Qf diffe rent frori loc�fion
—T'own_._ State Zip Code
City� •.
- 1
Telephone Number -- --B. Pumping Rec r+d - -- /
- � ._ __ 2. Quantity um ed:
1. date of Pumping Date / y p Gallons
3. Type of system: ❑ Cesspool(s) iii"''Septie.Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6, System Pumped By:
Nam � ,. V ,_f — ._ Vehicle icens Num e .._. .
ompany
« « «
7. Location where contents were disposed:
1p"ho «
t ,
a
o Ha 1 Date
ignalure of Receiving Facility Date
15form4.doc•03/06 System Pumping Record•Page t of 1
Commonwealth c rf Massachusetts
r City/Tow n of
to ;ng Recor
Form 4 DFp has provided this form for use by local Boards provided o here.. Before using ibis term,check with your
information must be substantially the same a
. Y Y y y Pumping Record must be submitted to
local to
the loBCat Board f Health or other approving they use, within 14 days frothe pumping dam m
accordance with 310 CMR 15.351.
A. Facility information �� � �� 1
Important: 1, system Location'
forms filling out �P i-°7� �
forms on the ( 'bµVEAL11I lit f A[RI E f:.I
computer,use Address„
only the tab key / _ ._.
to move your
cursor-do not
Zip Code
use the relurn
cityrro�
key. 2. System Owner.
_r.�_ __-�...._.
-"—� rocat�ort}
Address(ff different rn ia
__..,. ._�, ®......._. Zi Code
dityfrown ?� `
ephone Nurnher
S. pumping Record
of Pumping Date f3- -� 2. Ouantity pumped:
1. rations
3. Type of system: ❑ Cesspq€tl(s) [//septic Tank Tight Tank [} Crease Trap
(� Other(describe): .....� � ^
4, Effluent Tee Filter p�resent7 ❑ Yes U ,/No if yes, was it cleared? El Yes 2 'No
5. Condition of System:
6, System Pumped By;
vehicle L'r -_,dr — ..�.....— .... .
�- - —�- � nse umber
Name
Company
7. Location where contents were disposed:
__,,., .,._- — -- ----N ,,...�. ,.•—_ _..._� ._. .._,--.... tasty. ...,—......., :.f..;�•/—;^—.. ... _
,tt�
,g Fj '
Signature 4f Mauler
Signature of Receiving Facility -.",__..._..-_-.��. •-- C7ate o
system Pumping Record•page S of t
15form4.doc'03106