HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 WELLINGTON WAY 7/16/2019 off&
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Commonwealth of Massachusetts
City/Town of NORTH AVE
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System Pumping Record
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Form
DEP has provided this form,for use by local Boards f Health. Other forms may be used, but the
information 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 t
the 1 ca1 Board of Health r other approving authority it 1 1A days from the pumping date I
accordance with 310 CAR 15.35 �
Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use I the tab
key to move your Address
cursor-do in t NORTH A VE1 0,1845
use the return Giit `iown State Zip Code
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2. System Owner'*
ANTHONYTIZZINENTI
Address if different from location)
City/Town State Zip,
Telephone Number
B. Pumping Recoird
1. Date of Pumping bats 2,. Quantity Pumped: GaIlon
3. Component: Cessi 1 Septic Tank "i hit Tank El Grease Trap
[:1 truer srii �w...... ..
4. Effluent.Tee Filter present? Ej Yes E' N ol If yes, was it cleaned? Ej Yes 0 No
5. Observed condition of component pumped:
GOOD
. System Pumped By,
JAY CURRIER 76
,.,..��������m..��. �� Vehicle License u�wrru� .�,,, �....r��.m ...m .
Name r
TS SEPTIC & DRAIN
Company
. Location,where r nt nts were disposedo
GLS
7/10/19
Sign ire of Hauler Date
Signaturef Receiving, „i F ��iit r attach facility
receipt)
mm +c ipt Date
t f rm .doc*11/12 System Pumping Record.Page`I of°'I