HomeMy WebLinkAbout- Septic Pumping Slip - 111 PHEASANT BROOK ROAD 6/20/2019 RECEIVED
Commonwealth of Massachusetts
W
C"10ty/Town
System Pumping Record T,OWN OF NORTH )UV�I
. � TME T
i4EALT,�1,1 E, ,
Form
DEP has provided this form for use by loca,l Boards of Health. Other forms may be, used,, but the
information must.be substantially the same s that provided 'here. Before using this form, check with
your local Board of Health t determine the fora they use. Tl System Pear in Record must be
submitted to the local Board of'Health or other approving authority within 14 days from the pumping
data ire acclo rd anca with 310 C M R 15351.
important-
WhenA, Facility Informatmion
1. Sys Location:tilling out
forms the
computer, use
Warmly the tab Addfess
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key to move
your cursor-
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do not use the � I� �' �...,,
return key. State. ZAP _.
2. System Owner.
er I,Name
Az
Addfesof4ffefent4oniAeGat,40n)
state
Vn State__
zip e--„ _ .
Telephanewunibef-
B. Pumping Record
o
1.
N
Date of Pumping 2. Quantity PIn
I
1
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe)-
4.
Effluent Tea Filter present? Yes I yes., was it clean Yes No r
w Observedcondition of component pumped:
l,
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l !U "& nr� �al cl n mm"' ''w0✓�N�� ir`° �ry.• Ifl r f
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t5, rm4- 2 System Pumping Record Page of
Commonwealth
'ity/Town of'
System, Pumping Record
Form 4
DEP has rovided this,form for use by local Boards of'Health. Other forms may be, used, but the
information rust be substantially the same as that provided here. Before using this form,, check with
your local Board of Health to ' t rrnine the fora they use. The System Pumping Record must be
submitted to the local Board of Healthr other approving authority within 114 days from the pumping
data in accordance with 310, CMR 15.351.
6. System Pumped B
N
Gi,1(41 . e Lieens"uMFTI 91 -19
7'. nation where contents were disposed:
Signatwe.-of44aul Date-
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t5 arim .d o 1 2 System Purnping Record Page 2 of 2