HomeMy WebLinkAbout- Septic Pumping Slip - 440 BOSTON STREET 5/29/2019 �r
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System Pumpin,g ��° "
Form '' �"" "�" "' 1,4T
DEP has Provided
information MUst be,
this form for Use by local Boa
rds of Health,0
calsubstanti same that r f11 r ay 0 used',but the
the loca 80a,rd of Health or'other approvl System PU'Mpin,g Record Must besubmitted to
r mI the formthey Use-,'The #I thIrm�
�1'1F
1 check with your
ng authority'WithIn 14 days from the PUMping
accordance w1th 310,MR. 150351''o
date In
An, lift Infor
o
Important;When
Ming out forms M SYStern Locatiom
on tho computer,
OnlY the,tad e
key to move your Address
uuur-do not
use the return 1
key, Cft own
state
i
f
j
Address It"
"1
Stag
S. Pum
Telepp7oni Number °
pinj) Record'
'um O
Quantity
310 COMponeint: Cesspilool(a), Septic Tank Tight Tank Gallons—
Grease
El Other(describe
41,
Eiffluant,Too Filter present? Cj
Yes El No If yes,was It cleaned? YGs C) No
S. Observed condition Of am
ponent Pumped:
., system Pumped
Vehlole Licenso Number
Company
North'
t hig MA 0,1
7. Location where eon4nts were 41spo's'ed':
————-6-
Date
tilOMMUN of Raosivin,0Pa hl ' r allooh favility repel
pt) Date
frm . " s '2
8YOtem Pumping Record page j of 1