HomeMy WebLinkAboutSeptic Pumping Slip - 1200 SALEM STREET 8/2/2018 RECEIVED
Cornmonwealth of Mass-achimSefts
Cityffown of V21-.V1Zt'. AM3 0
9 , iiSy'stern Pumping Record rOWN 0 1 F NORTi1 MOOVER
HEAU rri DEPAR WOO'
Form 4
DEP has provided this form for use by loval Boards of Health. Other forms may be used, but the
information must be Substantially the same as thal provided here. Before using this form, check with your
local Board of Health to determine the kirm 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 outforms 1. Svstem L.0i7 t
on the co I mputer, on:
'--j I '�'
use only the tab
key to move your Address
cursor-do not
use the return
key cityrrown State Zip Code
2. S,/stem Owner,
Mune
retm
A�Idress(if rent from location)
-S-ta-toZiprCode
-
Telephone Number
B. Flumping Record
1. Dace of Punrping ZA 2, quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) 7.! Septic Tank F-1 Tight Tank El Grease Trap
Other(describe):
�A
4. Effluent Tee Filter present? ❑ Yes V No If yes, was it cleaned? M Yes No
6, Observed condition of component pumped:/--V,
6. !Zystem Pumped By:
Name Vehicle License Number
Wind River E nviron mental
Company
T lora ion where pont tswere ds used:
�Wvqljhlill W VT
r
0 fee
lure of Ro ty� '11! .m4T
—�-cei-vin-q- -(oriiic far-ifity re:r)o
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