HomeMy WebLinkAboutSeptic Pumping Slip - 370 FOSTER STREET 11/27/2017 �
Commonwealth of ��s ach,usetts
;i, City/Town of
System Pu Mping Record
Form 4
DEPhas provided this form for use by�oca| Boards of Health Other forms may be used, but the
information mum be substantially the same anthat provided hene. Before using this hono. check with Your
local Board of Health to determine the form they use The System Pumping Record must be submitted m
the local Board nfHealth o' other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15 351
A. Facility Information
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m"ooum/^*"s 1 System Location,
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�ev ^"'''~°" slate Zip Code
2 System Owner
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Telep�one-Number
B. Pumping Record
, Date n( Pumping 2 Quantity Pumped
3
Component Ceuapuo(o) Septic Tank [] Tight Tank [] Grease r'ap
Lj Other(describe).
4 Effluent Tee F/|!ocpreaen|? Yes No If yes, was it cleaned? 0j Yes E] No
5 Observed condition of component Pumped
/
OSystem Pumped By
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Name vox/*ru`e"oowomoa/-
VW d River Environmental
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7
Location where contents were U�npooaU
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