HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 780 FOREST STREET 9/8/2020 Commonwealth of Massachusetts RECEIVED
a City/Town of N. SEP 0 3
r
_ System Pumping Record 6FNUiTP1A;v� Yi
r Form 4 TOWN
HEALTH nEPAPTMNT
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 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, ! n ��
use only the tab 0 U
1
key to move your Address
cursor- not N
use the return G J
key. City/Town State Zip Code
2. System Owner:
Name
Hula
Address(if different from location)
City/Town State �y G Zip Code
97 r " aJo7�O�
Telephone Number
B. Pumping Record
1. Date of Pumping ZO
Date /d7 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:
J
6. System Pumped By:
e JlSt `,j�1f�, 8a 8/ 7
Name Vehicle License Number
Savice Pump*&Dram Co.,Inc.
Company
N Ratdin&MA 01864
7. Location where corrnte is were isposed:
LS I
�la� l2a
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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