HomeMy WebLinkAboutSeptic Pumping Slip - 139 ROCKY BROOK ROAD 12/19/2017 Commonwealth of Massachusetts
�f C ity/Town of 0, Pt0000e. RUN { alWMER
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the J
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 submitter tis
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
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2. Sy e Owner;
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Cityfrown State . .F,
Zip Code
Telephone Number
B. Pumping Record- _
1 Date of Pumping Ot �l
2. Quantity Pumped .__.
Gallans �� —
3 Componenk ❑ Cesspool(s) ❑- !§ptic Tank ❑ Tight Tank El Grease Trap
❑ Other(describe):
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4 Effluent Tee Filter present's ❑ yes If yes,was it cleaned? ❑ Yes ❑ No i
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5. Observed con �jjon of component pumped
6 S ., mPmP m dBy;
Nance Vehicle license Number
Wind River Environmental
Company
7 Lac tion where contents werm disposed:
Date
Srgndture of Receiuing Facitkty{or attach facility recap:) y Dafe
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System Pumping Record•Pala., i ;,+
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