HomeMy WebLinkAboutSeptic Pumping Slip - 1145 OSGOOD STREET 1/9/2017Commonwealth of [VW 3443C. usetts
City/Town of NOWA
System Pumping Record
Form 4
RE ElliTED
JAN 0 `,(!,
'TOWN OF" NOVFH A l',IDOVER
HEALTH DEPAFZIME,NT
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 CMR 15.351.
A. Facility information
Important When
wog out tonne 1. System Location:
on the computer,
use only the tab '1S.- OS
key to move your Ad ra3
cursor - do not
use the return
keY•
5. Observed condition of component pumped:
7. Location where contents were disposed:
Signature of R vl Illy (or attath facility rscelpt) Date
2. System Owner:
--CA' CA-646
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3, Component:
Other (describe):
6( ef-t-,
State Zip Code
Cesspool(s)
State Zip Code
Telephone Number
Number
2. Quantity Pumped:
Gallons
0 Septic Tank 0 Tight Tank 0 Grease Trap
4. Effluent Tee Filter present? 0 Yes 0 No If yes, was it cleaned? 0 Yes 0 No
e Number
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