HomeMy WebLinkAboutSeptic Pumping Slip - 545 WINTER STREET 5/16/2017 CL-
Commonwealth of I Ar-��- Ovsetts
city/Town of jq�j
System Pumping Record ���������������. P���'���
Form 4
DEP has provided this form fpr use by local Boards of Health.Other forms may be used,but the
Infarrnation 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
this local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Infonnation
vtom
i °�t 1. System Location:
UN 0*ft tab
key to
ORM•don
use Me MOMf `I
State Zip Code
2. Sy Owner:
N8
(1"le
%'/ ° AddllbJls
`nate Zip Code
B. Pumping Record Temepnene Number
n� 1. Data of Pumping "� c /
2. Quantity Pumped:
3. Component: Gallons
❑ C pools) [ "Septic Tank ❑ Tight Tank ❑ Grease Trap
Other F,
(describe):
4. Effluent Too f=ilter present? ❑ yes ❑ No if yes,was it cleaned? El Yes
No
5- Observed condition of component pumped:
6. Sys Pumped By.
vul"M License Number
r►Y
7• Location where contents wefts disposed:
-} Gate
of R np Facto-(o+'attach fedi mesal
M) Cate...
16farm4400-11/12 ,.