HomeMy WebLinkAboutSeptic Pumping Slip - 36 SHANNON LANE 11/27/2017 =� Commonwealth of Massachusetts
CityfTown of A,4ro;96ot, t2
System Pumping Record
Forret 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 tame as that provided here. Before using this form, check with you
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 clays from the pumping date in
accordance with 310 CMR 15.351,
A. Facility Information
Important:When
rolling out forms t System location
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2, System Owner:
Name
Address{if dl8erent from location)
Cityfl-own State _ _.
Zip Code
Tete�phon�e Number
�. Pumping Record
1 Date of Pumping D 1 t 2,02 Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) R?�eptic Tank ❑ Tight Tank
9 ❑ Grease Trap.
El
Tac-
❑ Other(describe);
4 Effluent Tea Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5 Observed c dition of component pumped.
6 Sys m Pumped By-
Name
Vehicle License Number
Wind River Environmental
Company
lqqatlon where conte were disposed.
uttr of Haul
er .. _..
Date
Srgnatur'e of Fceceiving Facility,Xr attach tacihry fcce+pt} CaEe ---