HomeMy WebLinkAboutSeptic Pumping Slip - 1980 TURNPIKE STREET 5/2/2016 Cornmor-wealth of Massachusetts
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System Pumping Record NORTH ANDOV,4
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, btio
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 fYV
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only the tab key Address
10 move your
cursor-donol
use the return City/Town Slate Zip Co
key. 2. S X-7 m Qw er.
Q .._ .1`_ ..ALL
Name e I
Address(if different from location)
City/Town State Zip Code "
-----------._.--- -
Telephone Number
B. Pumping e c o 1"d --- --- --
1. Date of Pumping bate 2. Quantity Pumped: Q c-)
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? (, Yes ❑ No If yes, was it cleaned? 2-Yes ❑ No
5. Condition of System:
6. Sy tem Pumped B ::
Name Vehicle License Number
w Aj ,
Company
7. Location where contents were disposed:
(9
Sig f" lure of Hauler ( Date
ig ahire of Receiving Facility Date
SformA.dor. 0310 System Purnping Record•Page 1 of t