HomeMy WebLinkAboutSeptic Pumping Slip - 30 WINDKIST FARM ROAD 6/7/2018 m
q�6
of Massachusetts
DO
F)Fli","�,,irfnping Record
- �. �r�(rvicted thl � Form for use by local Boards of Health. Other forms maj e used, but the
iili'ori 1W,i i i wst be substantially the same as that provided here. Before using this form, check with your
local r ; >f to determine the form they use. The System Pumping Record must be submitted to
the loc:it lis()°°<ard of Health or other approving authority within 14 days from the pumping date in
accoroan(:e with 310 CMR 15.351.
ftiforrnaflon
Impovt nit: When
filling out(nuns _oc(�'lJorC
on the cornputer,
use only the tab 2b ( ��_�' � �_..... ... ......_ .................
key to move your A d6 .z"
cursor-do riotMA
use the rc,turn � � �.1, , r<<(�ob°e�
key. �rr� State Zip Code
raLz I ••
(�
0 dirt Trent from location)
State Zip Code
Telephone Number
pffj� Lr .
1. F'Umping 2. Quantity Pumped: _._.
Date Gallons
3. � Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
' E ' (;r (rk'!scnl:ae):
4. L ui ,l -fee Filter present? ❑ Yes n No If yes, was it cleaned? ❑ Yes ❑ No
c-,ondition of component pumped:
6. Purnped By: �
Vehicle License Number
tiseptic 53 So. Kimball St., Bradford,MA
l
'i vide„>re contents were disposed:
Bradford, MA
Date
rpt I-+..1e
rf F;°cility(or attach facility receipt) Date
t5forrn4 dac°11/12 System Pumping Record•Page 1 of 1