HomeMy WebLinkAboutSeptic Pumping Slip - 89 WINDSOR LANE 5/21/2018 ,-IN Coommonwealth of Massa ch(Ase-fts
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System Pumping Record
Form4 `
DEP has provided this form for use by looal Boards of Health, Otheir farms may be used, but the
information must be substantially the same, ae;than.provided here. Before using this form, check with your
local Board of Health to determine the forrn 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 forms 1, System Location:
on the computer, c"
us®only the tab "�._. ._ .... ... ... ._._._.....'".~.~�'....___._._,_ . �`"'^.. ....._.__..._..____ ............._...___ .___..........__.__..._.. ...,_
key to move your Addres
cursor-do not
use the return _.__ _....__ .Y"t_1"`'.. `. i. ,. __... MA
Cit !Town __...._..____ ___..__._,
key. Y State _. Zip Code
2, System O er:
Name
rmrtr
Address(if differ.�._.._______._._.._. ........ . .,....._._..... .... ... ... _ _ ....______. .... ._._.. _ . _.. .. ._,.._�..._.
ent from Iocalkan)
Ckiyfrown Stale Zip Code
_ Telephone Number
B. Pumping Record
.__._...._�.__._..�._ � _
1. Dake of Pumping -� � . Quantity Pumped: = ...__._.___._._.
Hate Gallons
3. Component: ❑ Cesspool(s) ,"Septic Tank ❑ -right Tank ❑ Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes [ No
5. Observed condition of component pumped:
6. Sy Pp`m�ped By:�
Name Vehicle Llcense Number
Wind River Environmental
Company
7. Location where contents were disposed:
` 1.
ure of Hauler .. 6ate
Signature of Receiving Facgity(orattech fa+.ifity
Date _ .,..._..___.._.__.._...._.
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