HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 445 FOREST STREET 11/19/2020 RECEIVED
Commonwealth of Massachusetts NOV 1 91020
city/Town of
WN NORTH AN
System Pumping Record TOH ,°H DEPARTMENT R
4 Form 4
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 I
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 I
accordance with 310 CMR 15.351.
A. Facility Information
important:
When filling out 1. System Location:
forms on the /p
computer.use �V- _ \-ice
only the tab key Address
tomoveyour /� -
cursor-do not i �7own late
use the retum
key 2. System Owner:
Our-
Name
Address(it different from location)
Zip Code
Citylfown
Telephone Number
B. Pumping Record
1. Date of Pumping e—- 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) t�Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ------ _.------_.
4. Effluent Tee Filter present? 5DXes ❑ No If yes,was it cleaned? Rkles ❑ No
5. Condition of System:
frwrioa Uj%la-\LQU�
& System Pumped By:
ame Vehicle License Number
Wr
� _. .
7. Location where contents were disposed:
S bn
re o auler Date
---------- _ .--.-.—.-.-..__ - -- -- -- - -----
Signature of Receiving Facility Date
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