HomeMy WebLinkAbout- Septic Pumping Slip - 9 TURTLE LANE 5/29/2019 I
1
1
I
RECEIVED
��Yr�r�r���1>l��y�'Commonwealth a��iii (rrrr
f
Of Massachusett
City/Town of
ra
System
y II
Pumping4 a�UI
Record
Form 4
af
DEP has provided this form for use by local Boards of Health, Other forms mlay be used,,but the
Information must be
f
substantially the same as that provIded here,Before usingthis form
,iheck with your
loical Board of Health to determIne the,form they use,The System Pumping Record must,�e submitted to
the local Board of Health r
her,
accordance with 310 CMR 1 SI.351
b"01 ONO
Av Facility Information
Important',When
filling out forms 1 System Location
on the oomputer,
use only ft tabLfz,:�.11
keY to move your ATdresi
cursor-do not A/0
use,the,return city/ owe
State
Zip Code
System Ownen
t
Name
RU
Address(if different from location
City/Town City/Town Stag
Cod
C�7
Te ephona Number
B. Pumping
A3,/ e)
1. Date of Pumping
Date 2 Quantity Pumpedt,
E3 Ui' Septic Tank Tight Tank 11 Grease Trap
E] Other(describe),
Effluent,Tee Fliter present"?
No
If ,W9 It clamed? Yes No
5. Observed condition of component.pumped:
In o;
6 System Pumped
Name Vehicle loonse Num4e r
Company ;
LS
7. Location whel,re!'eobtiint,6,-'Weredispbsed0
�IRuNir-Tf Hauler
Date