HomeMy WebLinkAbout- Septic Pumping Slip - 1469 SALEM STREET 12/10/2018 t.rorn(`Y' on'N -clith of
Idyl (a l,.,ril,`1/T own o
�jmtem Fl�rr i� ►�i�r w : : �:.
Form
OOP I',as,provided thl!i">forrt-i for is u by Ic" 80 �'ov t''s c"t Hoalth. Othoi, forms niay be us,scl, but tlie
infor,riation must`b4s substr�rttially . rl,; xatyie ELF t tit flere, Before using thjofcrin,(.hee.kwith your
local Board of Health to d termin(,,the.form use:. `lThti'Sy:;tem Fumping Record rrtust be subtr►,itt d to �
the Ir;ical Board of Heiilth or other a,ppr-*n"'# Within 14 dar.a.; hf-oi7i lho patt`ii)in!;l d to in
accordance with 316 CMR 15351;
I
A. FacAlIty Info1"mflora
important:Wiam
tilling out forms 1, tsystom Location:
on the,computer, � N
use only the Wb
Ice move yf�ur r cl rc:,i$ M
y
catirsor donr�t
use(lie return t,,ityil'r�wrt
fsc^y.
Stan, Zip Mcrda
Systom Own0r:
eat
._ ..__._._: _.. . _. ....,..,,_..._., _....
4
r',ddrass(if differell,1`r jm locallon)
(.ityll'atWn State Zip,;:ode
Tcleohone Noinbor
B. Pumping RttVicoir"d
t, I)atE3 of 2, c; upritity{�t,�Cop,'.aN9:
Pumping etc, �rri"crns
1 Component. � � u��ci..C,uf;�} ��''Setrl.is:`wank C J "Tight`l'arti< r�� Grease Tr,.+p
i Other descwrise): _.. _... _w .. _..
4, FffloontTeo piltal,present' [..� �,i c; " '40 If yos, was 4 dearod? YfnP-':le
5, Observed condition of r.ompor(' 'il pi.twp��!11'
6. ;3ystem Pumped By:
Ixarna v"�hicle l.to4n„��I�Ittn7tr,�r
Wind Diver Environmental
t`,nmpany
7. lxclation w'iero contents wt rc;t.l`spof ed:
A ,
,t
W-40i;I-cure of Mauler Dato
t�lctn�u'ra of N`tdttatvlr��,�ar,�itty(or att;c.h f,,riirty ����Pal(,t) t�alr,
Vorrn4Aw I I112 system Pumr,iriij Rocord r Page 1 of t
j