HomeMy WebLinkAbout- Septic Pumping Slip - 151 OLYMPIC LANE 10/3/2018 Commonwealth Of MaS,"ChUsetts
6;- City/Town of D"'�JDRTHM'4i")OW f",
Sys�tem Pumping Record
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;a,.:,that provided here. Before using this form,check with your
local Board of Health to determine the form they use, The System Purriping Record must be Submitted to
the local, Board of Health or other approving 'ClUthority within 14 days from the pumping(late In
accordance with 310 CMR 16'.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
an the computer,
use only thelob
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
toQ 2. Systern 0
Ter)
? rr , ��
A'f _. ._
_ _:.______ _.�..W ____.. _ _._._ _ _ .__ ____ _._.
LZA
Address-(if dlfferent�frontIoqoil, )
State
Telephone Number
B. Pumping Record
1, Date of Pumping
Dote 2. Quantity Pumped: Gallons
3. Component: r7l Cesspool(s) Septic Tank Tight Tank El Grease Trap
El Other(describe):,
4. Effluent Tee Filter present? ❑ Yes No ll'yes, was itcleaned? Ej Yes No
5, Observed condItl6n of component pumped,
67'
6. Sys m urn ed By.
Name ce-
VehicleU nse Number
Wind River Environmental wt
Company- OVOKIol WWTP
7. Location w e e contents ere isAoued: 40 9 Poor M
rdo Me 019M
nature of Hauler 08te
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