HomeMy WebLinkAbout- Septic Pumping Slip - 63 CROSSBOW LANE 12/10/2018 Commonwealth of Massachusetts RECEIVED
City/Town of P"A oa)e oe-
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System Pumping Record '��OWN 0F W)kll AN00VER
-EAL"fli 0"Affl1%riENT
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 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 CUIR 15,351,
A. Facility Information
Important:When
filling out forms 1 Syste L
on the computer,
use only the tab
key to move your Address
cursor-do not R to C- MA
use the return
key. State Zip Code
2. System Owner-
Name
_1 c)
reran
Address(if different from location)
City/Town State Zip Code
...............................
Telephone Number
B. Pumping Record
ll. Date of Pumping 2. Quantity Pumped:
DateGallons--
3. Component: ❑ Cesspool(s) Septic Tank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yes El No If yes, was it cleaned.? Yes ❑ No
5. Observed condition of component pumped:
6. Syst rn roped By: 2wr
�ame --e—hi--c-,I,e se Number
V m-b-e-r-----
Wind River Environmental
Company
7. Location where contents were disposed:
'-fature of Hauler Date
signature of Receiving Facility(or attach facility receipt) Date
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