HomeMy WebLinkAbout- Septic Pumping Slip - 55 RALEIGH TAVERN LANE 6/20/2019 ,0%
Commonwva l assachusetts
:IVED
Z C /Town, of RECE
System Pumping Record
Form 4 �t4 OFNOR 7 J�i AND OVER
1,,ONN "PARTIMENT
DEP has provided this form for use by local Boards of'Health. Other foAoQylie ul sed-
,, but the
informatio n must be substantially the same as that provided here. Before using this form, check with
your local Board of Health to determine the,form they use. The System Pumping Record must be
submitted to the local BoI d of Hea,lth or other approving,authority within 14 days from the cur in
date i n accordance with 310 CM R 15.35 1.
.............. ........... ...................
A., Facility Information
llmportaM:
1., System Location.-
When filling out
forms on the
computer,use
ja
only,the tab Addfess-�-
key to move �j
your cursor-
do not use,the
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return key. Gityf-Tev ede
2. System Owner;
Add.re-s-s m4eGa#Gn)
State
G WHIM
il Vate
ZNp-Gode
it
Tetephene-Numbef�-
................................................................................... ....................... ..................................................... ------- ....................................... ................... ...... ....................
B. Pumping Record
..................
Date 2. Quanfity Pumped:
1. Date ofPu mping
3. Component* Cesspool(s) Septic an Tight,Tank Grease Trap,
Other(describe):
4. Effluent Tee Filter present? Yes If yes, was it cleaned'? Yes No
5. Observed condition of component pumped*
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t5fbrm4.d1oco 11/12, System Pumping Recl oar d Page I of 2
CommonwvijIth
Lr,
City/Town;
System,
Form 4
DEP has provided this form,for use by local Boards of Health Other forms may be used! but the
information must be substantilally the same as that provided here. Before using this rr , check with
your local it it hu to determinethe forte they use. The System Pumping Record! must
submitted to the local Board ofHealth or other approving authority within 14 days from the, purnping
date in acco rda,ncle with 310 C M R 15.351,
6. System Pumped. :
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9
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T Location where contents were disposed:
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fa '
y+eceipt) Date
t5f rm . ' 1 2 System "umping I Record Page