HomeMy WebLinkAboutSeptic Pumping Slip - 12 BARCO LANE 3/23/2017 Commonwealt of Ma sa husetts
City/Town of
System Pumping Record
few Form 4 9 f
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the 1
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.
------------A. Facility Information �
Important:When
ficin out forms 1. System Locati
g Y �
on the computer, ,
use only the tab
key to
rmo not your Address � I
y vA -- - �
use the return
Cit !Town ._.__ MA -........ —
key y tate Zip Code
rc
U 2. System Own,
r .
----
Name
ieavm
Address(if different from location}
City/Town State Zip Code
( p
Telephone Number
B. Pumping Record
mm
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) -Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditio pof comport nt pumped: q�q
° / .. . �w oYFo✓ MB7
ch9 MA:
6. System 4ed y.
Name Vehicle Licen
Wind River Environm ntal WIfiftiv Environmental
Company 163 Western Ave.
7. Location where contents were disposed; ()1oucester, MA 01930
- --- --- -- --- - -- ------ _
Signature- Blau
ler date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11112 System Pumping Record•Page 1 of 1