HomeMy WebLinkAboutSeptic Pumping Slip - 34 WILD ROSE DRIVE 5/9/2017 RECEIVED
COMMonw aMith of Nl� 'pus tts
System Pump Ing Record
FOrm 4
DEP has provided this trerm for use b .► t
lnt'orma�tkxl must be• y Boards of Health. Other forms may be used,but the
tlslly the same as that provided here. Before using this form,check with your
Board of Hftlh to determine the formthe local Board of theyu
►or other approving athority within 1se.The 4 System
sufrom the p mpi g date Ind must be
to
with 310 CMR 15.351.
• Foe---
MY
. 1. S
samoft Yom
f � gjwta rS M
2. System Ownar„ 71P-Co-de
i
(N
To Code
�E 1. Date or pumping .. r
3. 2. Quantity pumped. v?)
- Cas (s) ® Septic Tank 13 Tight Tank
Other( �; Greaq Trap
p• BtSu
Tes
FI p
S. O ® Yea ❑ Pio it yes,was It Cleaned? ❑ Y
condes lion of component Pumped: C Na
t3.
80101111 pum ay;
'Nehfde
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ftwh
dw 11/'17