HomeMy WebLinkAboutSeptic Pumping Slip - 141 REA STREET 12/19/2017 r Commonwealth'of Massachusetts �`J
City/Town of_ALk.0,4'A T igiliff"'PA,
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 lnformation —
Important:when
filling out forms 1 System Locatiow
on the ter Y1 clo
use onlyly the the tab 1
key to move your Address'-
cursor
ddress ,,cursor-do not ,t !1
use the return ,ice`_.f�11 ,_. ._..__... _........ ....... _.._.. MF`
key o
f wn State Zip Code
m1
m
2 System Owner;
VII11NA
Name
Address(if different from location) _.._.„_.,.. .. . . _ _.._.m. -------
State
.___..
CitylTown
State Zip Code
Telephone Number
B. Pumping Record
a1000Bate of Pumping 2. Quantity Pumped: ms
3 Component: r, Cesspools) [ Septic Tank ❑ Tight Tank [I Grease 1 rap
❑ Other(describe):
4 Effluent Tee Filter present? (] Yes No If yes, was it cleaned? Q Yes ❑ No
5 Observed condition of component pumped: I
A
6, System Pumped By
Name vehicle License Number
Wind River Environmental
Company
7 Location where contents were disposed: '_.flll
Signature of Nauta ` r d f
------
(9-Ml 374-2382
ignature of Receiving Facility(or attach fac.11ry receipt) Date
1
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