HomeMy WebLinkAbout- Septic Pumping Slip - 1773 SALEM STREET 10/3/2018 D
Commonwealth of Massachi.jsetts
City/Town of 06 01A 0(1111T 0 3 ?61181
System Pumping Record 1UPP4 01' 1 MNDOVER
A
Fomn 4 HE
DEP has provided this form for use by local Boards of Health.Other forms may be used, but the
Information must be substantially the sanne 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 approvifip authority within 14 days from the pumping date in
accordance with 310 CMR 15,351
A. Facility Information
Important:When
filling out form's 1. System Location:
on the computer,
.use only the tab
key to move your Address
cursor-do not
use the return MA
key. ;��iy'rrtiwn State Zip Gode
2, System Owner:
Address((f dffferent from location)
state ZlpGode
Telephone Number
m F3. Puping Record
W.
1. Date of Pumping lroe.- 2. Quantity Pumped:
Date Gallons
3, Component: El Cesspool(s) j"?jj Septic Tank El Tight Tank E:11 Grease Trap
El Other(describe):
r--10
4. Effluent To Filter present? Q Yes?,rNo If yes,Was It cleaned? n Yas No
5. Observed condition of component pumped:
6., System APed Vy:
�M e---—- — chicle License Number
Wind River Environmental
7. Location w ere co nts we s ecl:, Roftf,"Of WWTP
40 11 Rider M
aturd of auler
Si nature AC Ftecelvin Facili
(or attach facility receipt)
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