HomeMy WebLinkAboutSeptic Pumping Slip - 65 BROOKVIEW DRIVE 7/30/2018 rUra�u�"'�'rK�P" n��uI V9w�:am
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Commonwealth of Massachusetts "�02,0 1 i
.UJCity/Town of wovm 14 C)1
System. u n Record I l 1� i� R"WEN
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the
Information must be substantially the same as that provided here. Before using this form,check 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
Auing out forms 1. System Location:
on the computer,
`use alilythe tab
'keytolmveyour Addr s
o do nog
...
'use thei;retum.
own CI � �� µ
IgeY, tY State zip Code
2. System Owner:
r4 elk
Nara
.....S.F X C�
Address(if different from location)
i
Cityrrovrn
State
�.. p Code
Telephone Number
B. Pumping Record
1. Date of PumpingQat 2. Quantity Pumped: f '
Gallons
3. Component: ❑ Cesspool(s) [D Septic Tank ❑ Tight 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. System Pumped By:
Cris- i ;06L,
Name Vehicle License Number
company)
m
7. Location where contents were disposed:
� lw1
Signature of Hau16Date
Signature of Receiving Facility(or attach facility receipt) Date
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