HomeMy WebLinkAboutMiscellaneous - 480 SHARPNERS POND ROAD 4/30/2018 (5) fr�y'.''�;N ,; i ,,y,s fir, �, v,,.. q*. �R;, ,� y•t n �,`, ;, t
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US �T1'Si
y a Pumps 'g c� -
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j FEB 0 6 2007
` `bEP,has provided this form for use by local Boards of Health. The�S,,ystern Pu_mptngjFteco d must
be submitted to the local Board of Health or other approving autf,6rlt}-ALTH DEPARTMENT
A Facility Information
(, When fauns out',,. 1 ; System Location
,,
on the ' �
computer,usa';
only the tab key Address
to move your:;
pot, :.
wrser•�e CI /Town
use the r@tum state Zip Code
System Owner qlr
Name r
Address(if different from location) 1
Cityfrown State Zip e
-�9
`• Telephone Number
5
P
.0mi
n ..
, ec o d ..
p �R r
IAll
Date of Pumping Date 2. Quantity Pumped:
GaUons
3 Typo of system ❑ Cesspool(s) ptic Tank
❑ Tight Tank
(] Other(describe]
4 Effluent Tea Filter present?.❑ Yes No If yes, was It cleaned? ❑ YeVG—
p
5 Condition of System
Sy em Pumped By,
•
tt f 4 Y r!tt
mama
MW �;rYr .�Y,•� $5i: �- 't ••CC\l Vehicle Ucen#e Number0. _
r r,,_�,1".y' 111 \(� 1`•'�yr, � 1,1 ���
i ,y•,r .•4 �.:w.rlydl�rP1Q.��v1 i .J1 i1"\�J�i je..c w ; ': .,
7, location where contents were disposed;
a 1<< S(�nature of Hauler.;, Date
http://www.mass.gov/depJwater/a pp roy4ls%t5forms•htm#inspect .
t5fom►4.doa 06/03 System Pumping Record•Page 1 of 1