HomeMy WebLinkAboutSeptic Pumping Slip - 35 TURTLE LANE 8/15/2016 RECEIVED
OCIT I
Commonweal of Massachusetts
1 OWN OF,NORI AMDOVER,
Aj- 0' m6
Commonweal
City/Town of A "voll HEAJH DEPAFJM[LN f
I
System Pumping ecord
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 Ad I
r ss
cursor-do not
use the return LOA
key. cl own State Zip ade-
2. System Owner:
—T
Norm
Address(a different from location)
Ow I own State Y(P code ---
Telephone Number
U. Pumping Record
I. Date of Pumping 2. Quantity Pumped: �4p
Gallons —
3. Component: ❑ Cesspool(s) septic Tank ❑ Tight Tank D Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? 0 Yes ❑ No
5. Observed condition of component Pumped:
6. Sys m Pumped By-
vehicle License—N—um—b—er--
mpany
7. Location w ere contents were disposed:
Sign re 0 Laule:r�����
Date
Signature Or Kscelving Facility(or aiiich faclilly�recelpt) Date
t5form4.doc•11/12
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