HomeMy WebLinkAbout- Septic Pumping Slip - 74 WILLOW RIDGE ROAD 12/10/2018 RECEIVED
Commonwealth of Massachusetts
City/To wn of P ' OP0000Z.
System Pumping Record
TOWN OF I ANOOVER
Form 4
In u-i DD 1AR, rt
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 CMR 15.351.
----—-—A. Facility Information—--------------------------- .............
Important:When
filling out forms 1. Sy em Location,
4 on the computer, '-t , , ��oti
use only the tab
key to move your Address
cursor-do not t0c) V e"pz_ MA
use the return
key. City/Town State Zip Code
2. Systern Owner:
('0
Name
Address(if different from location)
—State ZipCode
Q
Telephone Number
B. Pumping Record
1 Date of Pumping bate 2. Quantity Pumped: Gallons
3 Component: ❑ Cesspool(s) Septic Tank [I Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? F-1 Yes No If yes, was it cleaned? F] Yes No
5. Observed condition of component pump
------------
6. Sys qePu p ed B
Nam Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
ignature of Hauter�t Date
-
d ' ,--- —i-9-1��tureof—Recei—vi-n,--g 17— -- ---- -acility(oraiia"ch facility "' - I-----Da I t e _
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