HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 19 MARGATE STREET 9/17/2019 � RECEIVED
Commo
nwealth of Massa1/1husetts
r City/Town of f h � C �r 1
kvSystem Pumping Record ��t=At-T R
tj Form 4 �+��T'�"�tT
DEP has provided this form for use by local Boards of Health. Other forms may be used
Information must be substantially the same as that provided here. Before using this form c
local Board of Health to determine the form the , but the
the local Board of Health or other approving authority within 14 days from the Pumping date
with your
y use. The System Pumping Record must be submitted to
accordance with 310 CMR 15.351.
P g ate In
A. Facility Information
Important:When
filling out forms I. System Location:
on the computer,
use only the tab
key to move your Addre3a
cursor-do not
use the return 1
key. City/Town =ft—
State I
C)
2. System Owner; ZIP Code
Name Y
Address(If different from location)
cityrrown _
State Zlp Code —"'
B. PuM tp' y'n Record Telephone Number
1. Date of Pumping //���
Date 2. Quantity Pumped: C,'t.._�
3. Component: cations
❑ Cesspool(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:
C)
6. System Pumped By:
A n t,v___ 11�
Name 3
61
5 Hallbergg
Service Pumrinb train Vehicle License Number
Park
Company ea mg i �y
7. Location where contents were disposed:
LSl
S g alure of Hauler
Date
SlBnaturo of Recelvin8 Facility(or attach fsollity reoolpt) Data
t5form4.doc•11/12
System Pumping Record-Page 1 of 1