HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 SAW MILL ROAD 7/31/2019 Commonwealth of Massa RECEIVED
City/Town of a chuse#ts L :j 1 2019
—�-�`�'t Vl D�U V r ��
System Pumping Record ply ppNORTWAND11111
Form 4
HSALIH 0 AHTMEN7
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the
Information must be substantially-the same as that provided here. Before-using this form,check w
Jowl Board of Health to determine the form they use.The System pumping Record must be s wit your
the local Board of Health or other approving authority within 14 days from the ptamping date lnubmitted to
accordance with 310 CMR 16.351.
A. Facility information
Important:When
tilling out forms I. System Location:
on the computer,
use only the tab LADM i key to move your Address
us ethe et not / h
use the return Ci /Towi•rown LV �� n A A �
y�— state G"��[t15
� n 2. System Owner: ZIP Code
-Name
earn:'
Address jlf different from location)
i
Cl WWI
State hAb
Zip Code'
B. Pumping Record Telephone Number
1. Date of Pumping 7 a5 ��00
Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) [Septic Tank
❑ Tight Tank Cl Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
If yes,was it cleaned? ❑ Yes [] No
5. Observed condition of component pumped:
6. System Pumped By:
IC
Name Vehicle License Number
5ervicc Pumping&i�rnut,.,�,. .�. '
Company NorthRw&g,MA 018&
7. Location where contenlsYwere d si posed:
1
Siler .
Date
518noturo of Raoeivin8 Facility(or attach facility receipt) Data
151!=440c.11/12
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