HomeMy WebLinkAbout- Septic Pumping Slip - 336 SHARPNERS POND ROAD 12/10/2018 Commonwealth of Massachusetts
City/Town of PrPooty-ce-
System Pumping Record
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 Repor,0 must be submitted to
the local Board of Health or other approving authority within 14 days from the pdmo ng date in
accordance with 310 CIVIR 15.351.
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A. Facility Information
(Y'
Important:When
filling out forms 1. System Location,
on the computer,
use only the tab
key to move your Addr
cursor-do not MA
use the return - ----------
key. City/Town State Zip Code
Q2, System Owner:
. ........ --------
Name .
Address(if different from location)
City/Town State 'Zip Code
----------
Telephone Number
B. Pumping Record
W
1 Date of Pumping 2. Quantity Pumped: 15
Date Gallons
3. Component: El Cesspool(s) Septic Tank F-1 Tight Tank r-1 Grease Trap
El Other(describe): ............
4. Effluent Tee Filter present? Yes F] No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pump
............
6. Sy m Pumped By:
_ __ �,........... __
Name Vehicle License Number
Wind River Environmental
ny
7. Location where contents were dis sed:
ture o aule Date
Signature of Receiving Facility(or attach facility receipt) Date
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