HomeMy WebLinkAbout- Septic Pumping Slip - 333 RALEIGH TAVERN LANE 10/9/2018 Commonwealth of Massachusetts R E C E
City/Town of
(All 0 a ?01�1
System Pumping Record
Form
N`W'�01-"NORI n-i N',DOVEn
4
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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 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 approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility information
Important:When
filling out forms 1. System Location:
on the computer.
use only the tab
key to move your Address
cursor-do not
use the return —,. /v() ,
Ivey. City/Town
State Tip�Code
2. System Owner:
4 0
Name
Address(if different from location)
State ziP<90'-'e
17 - Y.
Telephone Number
B. Pumping Record
2
1. Date of Pumping 76a—te C 2. Quantity Pumped:
-Gallons
3. Component: F1 Cesspool(s) �ySeptic Tank M Tight Tank ❑ Grease Trap
El Other(describe):
4. Effluent Tee Filter present? R Yes No If yes, was it cleaned? El Yes F-1 No
5. Observed condition of component pumped:
nncl
6. System Pumped By:
Name Vehicle License Number
s-
Company r
7. Location where contents were disposed:
IS D
eo 9�f
Signature of Hifuler Date
Signature of Receiving Facility(or attach facility receipt) Date ---------
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