HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 202 FOSTER STREET 7/15/2020 r Commonwealth of Massachusetts vEp
C ity/Town of IL A n c�Q V CY ,RECE�
System Pumping Record �UL 5 ZO
Form 4 vER
10 OF NDRI et j
DEP has provided this form for use by local Boards of Health. Other forms maj �5ut 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 to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, l
use only the tabQ
key to move your Address
cursor- not N . A 0 v n ,/1 ts� �1 Sip
use the retet not
Cit /Town '"1 V
key. y State Zip Code
2. System Owner:
Name
nv�
Address(if different from location)
City/Town State f _ Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ��
p g U Date � 2. Quantity Pumped:
Gallons
3. Component: ❑ 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:
Ca�C)
6. System Pumped By:
1 Cat Cot.m Q +-,%o RaS,I�
Name Vehicle License Number
Service Pumping&Drain Co.,Inc
Palk
Company North Retadin&NA01864
7. Location where on n'�s-were Ispo es d:
�- -7 /l U 1 2-0
Signatur of auler Date
SignatuO6 of Receiving Facility(or attach facility receipt) Date
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