HomeMy WebLinkAbout- Septic Pumping Slip - 857 CHESTNUT STREET 10/3/2018 Commonwealth of Massachusetts
l City/Town of " '. ��CT 0 3 C I f
SY-Stem Pumping Record
Form 4
pEP has provided this farm for use by local Eloards`of Health, Other farms rnay be used, but the
information must be substantially the same 95 that provil ed here, Before Using this fcmn,check with your
local Board of Health to determine the farm they use, The System pumping Renard must be submitted to
the local Board of Health or other approvinci authority.wil:hin 14 days from the pumping date in
accordance with 310 CMR 15.3,51,
A. Facility Information
Important:When
filling out forms 1. System Location.,
on the computer, P
use only the tap [,,,,. '"" ,
key to move your Addres
cursor-do not
use the return MA _
key, City/Town ...W. .,__.._
State' Zip .'ode
2. System wrier;
�& .r
Name
ion
C€tylTown
Male
Telephone Number
B. Pumping Record
1. Date of Pumping CJCG� � => ? ._.._.p 9 Dale _" 2�_: Quantity Pumped; _
Gaquns
3. Component: ❑ Cesspool(is) (1 Septic Tank ❑ 'right Tank CJ Grease Trap
0 Other(describe):
4, Effluent Tee Filter present? V Yes D 'lo If yes; was It cleaned? Yos ❑ No
5, Observed condition of component pumped;
6. SysNa;it aped By:
1/ehlcle license NlWniber
Wind River Environmental
Com an How. I WVM
T Loc on where contents wer t posed:
8r
dfo
f �
re of Hauler _...,
�f)ate
S :l,i
ignature of Rece€wing Fa, — (or attach facility recviot} Date'ry
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