HomeMy WebLinkAbout- Septic Pumping Slip - 125 JOHNNY CAKE STREET 7/2/2019 ..
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0 Co,mmonwealth of Massachusetts
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City/Town ,Q ,
System � �0
Form 4 ,
'All
DES has provided this forma for use by local Boards of Health. th r formic may be used, but the
information must be substantially the same as that provided Dare. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record mast be submittedt
the local Board of Health or other approvirig authority within 14 days from thepumping date in
accordance with 310 CIVIR 15.351,
A. Facility
Important:When
filling out forms 1, System Location:
on the computer,
use only the tad
key to molveyour ,,res
cursor notthe retu�rn NORM A 1
useCit ff r� State l Code
2. System Owner:
MARK WEBSTER
Name
Address if diffelrent from location)
... , . , ... . .mmm-..mm..mw
fit /Town State Zip Code
lumberTelephone
p1l
B, Pulm� ng, Record
6 21 19 15100,
1 Date of ire Date 2. Quantity Pumped: Gallons
3. Component* Cesspool(s) Septic'Tank Night Tank Grease Trap
[] Other(describe)'-, ..�...m m . ..�
4. Effl' en 'ee Filter present? El Yes If yes,, was it cleaned? Yes N
5 Observed condition of componentm e a
O
6. System Plumped y
JAY CURRIER, 9 6
umr,
'S SEPTIC & DRAIN
Company
', Location re contents were dispose:
G LS
21 19
gnature of Haulelr Cate
Signature olf'Receliving�.. Facility r attach facility receipt) It
t f rr .0 s 11/12 Systern Pumping Record Image 1 of I