HomeMy WebLinkAboutSeptic Pumping Slip - 1801 TURNPIKE STREET 4/11/2017 (2)important: When
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Commonweal
City/Town of
System Pum
Form 4
s ac usetts
ng ecord
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
1. System Location:
_Zea,/
Address
"MP/7X ,011-4
City/Town
2. System Owner:
MA
State
Zip Code
Name
Address (if different from location)
City/Town
State Zip Code
0 978" eer /212--
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component
1/2W/7
Date
2. Quantity Pumped:
C:1 Cesspool(s) El Septic Tank El Tight Tank
El Other (describe):
Gallons
Grease Trap
4. Effluent Tee Filter present? 0 Yes Da- No
5. Observed condition of component pumped:
OA'
6. System Pumped By:
Name
Wind River Environmental
Company
7. Location where contents were disposed;
If yes, was it cleaned? 0 Yes El No
Vehicle License Number
Wind River Enviiotunental
163 Western Ave.
Gloucester, MA 01930
Stewarts Septic
58
Signature of Haugradfont mAcri 835
Signature of Receiving Facility (or attach facility receipt)
Date
Date
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