HomeMy WebLinkAboutSeptic Pumping Slip - 164 VEST WAY 11/27/2017 -� Commonwealt of ssachuset s
= City/Town of
System Pump ng Record
Fora 4
DI=P 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 Evocation:
on the computer. ]�u
use only the tab
key to move your Address
cursor-do not �/ -
use the return Vncd( _ -..._ . MA
key CityFfown State _ Zip Code
Z System Owner:
Name —_..._ _ .. ... . -- - -• --•-- ------_ . _.
rmm
Address(if different from location)
CitylTown /State p- Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumto `! --- — / -� •—
p g date �. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
E
6. System Pumped By:
SLAV W-,(ivtx—
Name _ Vehicle License Number
Wind River Environmental
Company _ --_-
7• Location where contents were disposed:
Signature of Hauler`—
Signature of Receiving Facility(or attach facility receipt) bate
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