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HomeMy WebLinkAboutSeptic Pumping Slip - 30 MILL ROAD 4/11/2017 Commonwealth of Massahusetts 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 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 Important:When filling out forms 1. System Location: ` on the computer, `1 use only the tab /� c.h✓ ... rtA- --- -- - - - ..... .. . .. - - -- - - key to move your Address ,-- cursor-do not �7 / use the return MA C/ ( �� key. City/To n State .Zip Code 2. Syste Owner 17( YM Name -- ----- B71gn Address(if different from location) -- — - ..,....... CitylTown State Zipo c - - 07 Telephone um er B. Pumping Record - -- ---............... 1. Date of Pumping ©ate - 2. Quantity Pumped: Gal ons 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 co tion of caro onent pumped: - .... ........................... .----- ---- i 6. System P ed B —_ - -- - Name Vehicle License Number Wind River Environmen l Company Wind River Environmental 163 Western Ave. 7. Location where o disposed: Gloucester, MA 01930 I IC_h, MA, Signatu€e # aur tate Signature of Receiving Facility(or attach facility receipt) Crate t5form4.doc• 11112 System Pumping Record •Page 1 of 1