HomeMy WebLinkAboutMiscellaneous - 39 PLEASANT STREET 4/30/2018 3g PLEASANT STREET U-2 �
2101055.0002.0
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Commonwealthjof&assacbusetts RECEIVED
City/Town of �� 3 2008
a System Pumping Recor
Form 4 TOHEAOLTH DF NoC-PARF NORT TTH M�V
DEP has provided this form for use by local Boards of Health. Other forms may be used, b t e
information must be substantially the same as that provided here. Before using this form, c eck 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 1. System Location:
forms on the n
computer,use
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
`-
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Name
Address(if different from location) -
City/Town State Zip Code
ql?- baa - bbs7
Telephone Number
B. Pumping Record
1. Date of PumpingDal2tpl"� 2. Quantity Pumped: Gallons
oC�
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? Ej Yes ❑ No
5. Condition of System:
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cow
6. System Pumped By:
VAg0 tai(.p
Name Vehicle License Number
(�✓�n �GI
Company
7. Location where contents were disposed:
.L.S.D, �2�(d
Signature,o,Wtiawwct 4 Date
Signature of Receiving Facility Date
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