HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1403 GREAT POND ROAD 7/17/2019 ur"MMonwealth
Of MasSachusetts
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Umpling Record
Form 4
TOW,t4 OF R`1-
HEALTH DE!F)A[jTM'E'NT'
DEP has Provided this form for Use b Y Cal
Information li line tP
Other
that Provided here.
using this form
health Pumping Record
800ordance with 310 CIAR 150351, thorny within d from
the PUMPIng date in
Ao Fac I'll i 11ty Informatl'o"i
Im ;When
01'llng out forms SSt c
o the computer, "�
use only the tab
key to Move your Address Wool
.
urSor-do not
use the return
key* City/Town
ZI Cede
Name
two
Mdrese
B. Pumping, Telephone Number
R,ecord
Date Of Pumpinq
20 Quantity,PUmped,,
3, COMPonent, El Cesspoo,qs) W,SePtic Tank Tight Tank Grease Trap
Gallons
Other(descrlbe),:
4, Effluent Tee Filter Present? 0 Yes 0, No Ify", w8s It cleaned?
YeS N
Observed condition Of cow
ponent Pumped:
System Pumped
Name
Im
1
0TV1,00 N'mP� i Awe ' � Number
Park
Company ,
701 Locatlon where contents were disposed,,
w
$19nd urel
Date
819malura or M60,01vina Foollily(p,r alloob(60111ty recelpt) Date—
rm,44a 11112
sm 'uN Record.Page 1 off'