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HomeMy WebLinkAboutSeptic Pumping Slip - 86 WILLOW RIDGE ROAD 3/9/2017Important: When filling out forrin on the computer, use only the tab key to move your cursor - do not use the return key Commonwealt City/Town of System Pumping Record Form 4 itA1\10)\15k DEP has provided this form for use by local Boards of Health. Other forms ma0p00,,:14 information must be substantially the same as that provided here. Before using thi*.le* heck 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 1, System Location: Address City/Town 2, System Owner: 4115 /2/q Name MA State Zip Code Address (if different from I on) Cityfrown State TeIepho Numbe Zip Code '7! B. Pumping Record 1. Date of Pumping 3. Component: 2. Quantity Pumped: Date Cesspool(s) a-§er-Ac Tank CI Tight Tank Other (describe): 4. Effluent Tee Filter present? E Yes Er1V- 5. Observed candler f component pumped: 7:57-e7 Galloris El Grease Trap If yes, was it cleaned? Yes 0 No 6. System Pumped By: Name Wind River Environmental Company 7. Location where contents were disposed: Vehicle License Number signature of Hauler Signature of Receiving Facility Or atteoh facility receipt) Vi(WiTz 40 S .nr St LeraOhyr a (978) n74 23 21 835 Date Date t5fOrm4.4100. 11/12 System Pumping Record • Page 1 of 1