HomeMy WebLinkAbout- Septic Pumping Slip - 624 BOXFORD STREET 5/29/2019 r
1
3yyWH r i 4'y J it rf
V' �N' krir�4
Or
i %///,lrrMmE
,F %
uommonwealth o' MnA-taptusetts
o rei tr-
VIA f°aWffstem e�
v1 r
Pumping
Record
1 rvrl�k"J!Y�VY��jl�
uW& uIW. iRl'frry l/ry li1PW,IY'l!!
For
DEP has provided this form for use by local Boars of Health, Other forms may be used,but the
Information must be substantially the same as thait provided here, Before using thIs form, check with your
J
local card, Health to determine,the form they use.The System Pumping, Record must be submitted t
the local,Board of Health r tiapprovingauthority withinfrom the t I date In
accordance' with C i
An Facility
Important: n
MlIng outf . System Location,
on the computers a
use only the t 6
key to move your Address
cursor o.do,not Avvi.nvcj,�
use the return
fit '
State
ZIP Code
1
, System Owner:
0 a"LL,
Name
reati(it different from location)
CIty/Town state
'lp Cod-7w I - 4q4
l iy-Number
S. Pumping Record;
Date m lni
� � ,t
J
Gallons
f
, Component,* ' C08SP00i Septic Tank El Tight
Tank El Grease Trap,
Other(describe):
Effluent Te,e Filter present? Yes El No' If Yes,was
It cleaned? E3 Yes N
6. Observed condition of component -urn- dl
SYtm Pumped y
f
)Ioi n if) e'N
Name -
Vehlole Lloensa Number
Company
u
Date .
r
f
Slonatura alf IR 810,he F0,0111tyWinch flilt r1, It
system Pumping,Repro PIP I V/