HomeMy WebLinkAboutSeptic Pumping Slip - 2211 SALEM STREET 10/16/2017 RECEIVED
Commonwealth ssa hu etts
City/Town of
) C
le d)'4t 101,111,1()F NORVI ANM0,111-t
System Pum Yijg c r THANDOVER -lLfli DE["ARMENT
Form 4 HEA
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 1. System Location,
forms on the
computer,use
only the lab key Ad�cess
to move your C)
cursor-do not
use the return City/Town state Zip Code
key, 2. System Owner:
V"- Ah.� Y, Coo Y–\
Name 7—
Address(I(different from location)
Cityfrawn _, State Z' Code
Telephone Number
B. Pumping Record
1. Date of Pumping2. Quantity Pumped:
-6
ateGallons
3. Type of system: El Cesspool(s) Septic Tank El Tight Tank 0 Grease Trap
❑ Other(describe): ------ .......
4. Effluent Tee Filter present? Q Yes 1lo If yes, was it cleaned? Yes CL–leo
5. Condition of System:
_. __.._.__.__ _ .. _._ ___._ 0-0
_ .. __..__ .. _
6. System Pum ed B
)
K
Zo _y:
Name Vehicle License Number
Campany
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility pace
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