HomeMy WebLinkAboutCesspool - Septic Pumping Slip - 432 SALEM STREET 8/8/2019 Commonwealth of Massachusetts RECEIVED
System Pumpi g ecord AUG- d 6 � jg
Form 4 T4WN OF N0N71RiA%gDyVgR
DEP has provided this form for use by local Boards of Health.Other-for 14a- ,LTH 6E;j�
Information must be substantially the same as that provided here.Before using this form check form may be used,but the
local Board of Health to determine the form they use.The System Pumping Record must be s
the local Board of Health or other approving authority within 14 days from the Pumping date e k with your
accordance with 310 CMR 15.351. ubmltted to
p g e in
A. Facility Information
Important:When '
tilling out forms I. System Location:
on the computer,
use the tab
key to moveonly your Address �J
cursor-do not
use the return �y
key. Clty/Town -4,__
_�I State O T
� 2. System Owner: ZIP Code
Name
� I
Address(If different from location)
I,
Cl 'WWII
State Zip Code
97�� g�7_ 41�3
B. Pumping Record TelephcneNumber
I
f I
1. Date of Pumping 7`3 C) 2, Quantity Pumped: G f
Date
3. Component: Cass ool Gallons i
p (s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
If yes,was It cleaned? ❑ yes ❑ No
5. Observed condition of component pumped:
00d
6: System Pumped By:
yn
Service Pumping&Drain Co.,Inv Vehicle Uleensa Number
Company NorthReading,MA01864
7. Location where con -Ktq(b were a dtspo d:
Signature —
of Hauler Date
S18naturo of Roceivin8 Facility(or attaoh faotlity recelpt) Date
t5formCdoo•11112
System Pumping Record•Page 1 of 1