HomeMy WebLinkAboutTitle 5 - Septic Pumping Slip - 137 ANDOVER STREET 6/20/2019 u
Commonwealth
ity/Town
1"JI
System Pumping Record
'H AMOVER
�NOR,`�
TOWN OF
Form 4 HEALTH DEpAF
IT,MENT
DEP has provided this form for use by local Boards f Health. Other forms may be used,, but the
information must substantially the same as that provided here. Before using this form, check with
r local Board',of'Health to determinethe fora they use, The System Pumping Record must be
submitted to the local Board olf Health or other approving au rif within days from the pumping
date in accordance with 310 CIVIR 15.351.
A. Facility Information
Important: I. System Location:
When filling out
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only the tab �„. .
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tab
2. System Owner:
Neme
Address,
i
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B, Pumping Record
1
1. Date f Pumping � 2. Quantity Plumped: III n
3. Component: Cesspool(s) Septic Teak Tight TankGrease'Trap
Other(describe):
1
4.
Effluent Filter present"? "es If cleaned?
N��
f
J
5. Observed condition of component r , ed
C
III oai'S 0
,A V11,
t5f rm � ' o 1 12. System Pumping Record Page,I of
Commonwealth of Massachusetts,
City/Town of
v
D
System, Pumping Record
Form 4
DEFT has provided this,form for use by local Boards of Health. Other forms may be usedl but the
information must be substantially the same as that provided here. Before using this form, check with
your local Board ofHealth to determine the form they use. The System Pumping Record must,be
submitted, to the local, Board of Health or other approving authority within 14,days from thie pumping
date in accordance with 310 CMR 11 5.351,
................................. ...............
6. System Pumped By:
Name— Whi joens u
Gefffinfp) WF'Y W-41
7. Location where contents were disposed,
17-
eW
Sign,ature-of-Hai
000)
Signat we-off Receiviii effity(or attadvfaejMy-feaeiipQ— Date
t5form4.doce 11/12 System Pumping Record Page 2 of 2