HomeMy WebLinkAbout- Septic Pumping Slip - 1014 TURNPIKE STREET 10/3/2018 J!,
Commonwealth of Massachi..isefts
ITO C ity/Town of 0 3 ?01 18
kz
SYstem Pumping Recard
Form 4
DEP has provided this form for use by local Eloceirds o"HE) 'Ith. Other forms may be used, but the
information must be substantially the same as that provi+Zcl here. Before using this fonts, check with your
local'Board of Health
ealth to determine the f6rm they use, The System Pumping Record must be submitted to
the local Board of Health or other approving authority wlt)ln 14 days from the pumping date In
accordance with.310 CIVIR 15.361,
A. Facility In-formation
Important-When
filling out forms 1. System Loca ion:
on the computer,
use only the tab
key to move your Aldrp L
cursor-do not
use the return _k�pC-- ---- MA
key, City/Town State
Zi� Code
2, Syst Own
State Z117Code
Telephone Number
B. Pumping Record
I A
1. Date of Pumping 2. Quantity Pumped:
Gallons
3. Comitionent: n CessPool(s) E-1 Septic Tank Ej Tight Tank [-] Grease Trap
P1 Other(describe);
4. Effluent Tee Filter present? Ej Yes Jqo If yes, Was It cleaned? E3 Yes, [�"No
5. Observed condition of compohentpumped:
m u A
6' S5 6
� a Mped By:
Wind River Environmental
Company
7, Locat on where contents VMre disposecio, F3Mftfdo MA 01835
atur f Hauler Date
rowipt) Date
dlin-a-t—o"Wof R-'ei—ce—Ki—Ing—Fadfity"(fir' facility .......
attach
t5f6rm4.doc-11/12 Syctem Pumping Record-Page 1 of 1