HomeMy WebLinkAboutSeptic Pumping Slip - 162 HAY MEADOW ROAD 3/31/2016 �r, f M } n F17,♦Mti yip,a t,�Y
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DP has'provided this forty for use by local Boards of Health. The Pysteim,pumplh gcord must
be submitted to the local Board of Health or other approving autho Ity.
Ali Facility Inforr afion
When*filling filling out � : : S stem Ldcatlon '` "�;
Y
�forms,onthe.': t
;: .computer,use
only the tab key Address
to move your
arras do not /�-
use the return City/Town State Zip
I
� ;,:, � Code
System owner
f:. r
Name : r
Address(If different from location) .
Clty/Town State >�P
C
Telephone Number
u Ping Record
a ' 1 Date ofPumping oat 2. Quantity Pumped;
Gallons
'.Type of system:.
y Cesspodl(s) Septic Tank ® Tight Tank
® :Other(describe).
'Effluent Tee Filter present?,[3 Yes, No If yes, was it cleaned? [I Yes (� No
6. ondltIon of System `
e;)
r
Sy emPumpetl 6y:
l
,
ame Vehicle License Number
V
' ' 7 locabgn where contents Were disposed:
Y'
S(gnatureof Hauler,,d�r Date
httpJ/www mass gov/dep/water/apprpva,ls/t5forms,htm#Inspect
t5fom►4 doc•06!03 System Pumping Record -Page 1 of 1
Commonwealth of Massachusetts
Massachusetts
system
� PrFel
111
system Owner System Location
Date of Pumping; 7/6_Quantity Pumped.
No Yes ❑ Uk: No ❑ Yes
System Pumped by: Fa&dft License#
Contents transferrred to : ire ter Lawrencean'tar �iatrict
Date: Inspector: