HomeMy WebLinkAboutSeptic Pumping Slip - 165 CARLTON LANE 5/30/2017 Commonwealth of rar wichu etts
City/Town of
System Pumping Record
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
Wal 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. RECEIVED
A. Facility Information e ",o ?017
ad tomw 1. System vocation:
at the conVuw, 1 F t4 lw4 �
use Only the tab PoRTMENT
key to Addmes i
r°
use the room
key.
state Zip Code
2. Syat Owner.
Norm-
z
AOOresb(ir dflrerent from IOWtIOri)
Clty/Town State Zip Cade
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Telephone Number
. Pumping Record
1. Date of Pumping r: <> f
' i 2. Quantity Pum
Gallons
3, Component: ❑ Cess �f
Pools) ®peptic Tank 0 Tight Tank ❑ Grease Trap
❑ other(describe):
4. MOM Tee Filter p nt? ❑ Yes ❑ No If yes,was It cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
S. Sys Pum By:
4 ' Vehlde t.mse Nwnber
m►
gy ) . ...
r• Location where contents were disposed:
nature
a Hater
w- u
8ipnature o1 Recelvinq FactlNy(pr attach fadlltyr recelpt)Y _ ®ate
ts%m'41.0100-11/12