HomeMy WebLinkAboutSeptic Pumping Slip - 1780 OSGOOD STREET 7/5/2018 Commonweal P
'FC'E-j'VF.0
th Of Massachusetts
city/Town of
Systsm PUMPIng Record 3UL 5ZO --R
FOrm 4 OW,
DEP has Provided this for
Information m for Use by-loca
must be substantiallyI Boards of Health. Other forms may be used, but the
local Board of Health to the 88 that Provided here,Before,using this
the determine the form they use.The tb� %check with Your
local Board of Health or other approving authority. System Pumping Record
must be SubmItted to
A. Facility 0nfC'rM'jtj
Important-, pn
W18n lilting ouL I-
r
arms
on.the
computer,use
only the tab 1(0
10 Move Your Address
cursor-do not
use the return Ci ovwvn
I(ey.
Systsm Owner; state
YIP
ame
Address(1
f_dW
arenqrOM 100affon)
of%Town
state
ZIP Cad
Z7
Telephone Number
B- PUMP#ng Record
1- Date Of Pumping
nate 2. Quantity Pumped, A) kv
3- Type of system: gallons
C'-qsPc01(s) 0 5eptic Tank ❑ Tight Tank
❑ Other(describe).
4. Effluent Tee Filter Present? yes No
5. Condition of system: Q11 year Was It Gleaned? C2 Yez No
Ile, 6"'/ "D
6* system Pumped BY.
Mame
Vehfol
L
ComPany&Lr-Q-�2-e
7. Location where contents were disposed:
Signature or Mauler -------------- Date