HomeMy WebLinkAboutSeptic Pumping Slip - 45 BEECHWOOD DRIVE 7/14/2016 RECEIVED
Commonwealt of Massachusetts
TOVVN OF NOMI
City/Town
System Pumping Record KALUi
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Addr
cursor-do not
use the return Cl
key. Cl own Zip Code
2. System Owner:
4
Name 4 ct
Address(K dllferent from locatbn)
Cityrrown State Zip Code
z)-3
Telephone Number
B. Pumping Record
I. Date of Pumping
Date 2. Quantity Pumped: a--
G ns
3. Component: ❑ Cesspool(s) t,5�,'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If Yes,was it cleaned? ❑ Yes ❑ No
5, Observed condition of component Pumped:
6. System Pumps B
Na Vehicle License Number
Comp ,e
7. Location where contents were disposed:
7
Sip lure or Hauler —
biFe Coe-,
Signature OT Receiving Facility(or attach facility�receipt) —Da—te-------
t5fomAdoc•11112
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