HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 PATTON LANE 11/23/2020 commonwealth� �f�,Massachusetts
,
City/Town of �jf, RECEIVED
System Pumping record NOV 2 32010
• �
Form 4 • ''
it TOWN OF NORTH
ARTMENT R
DEP has provided this form for use by Wal Boards of Hea . i�r ins may be used, but Health. "
kdonymdion must be substantially the Sams as that provided hero. Befrnie usft this form, your
local Board of Health to detarmirm the form they use_The System Punq ft Record must be bmitted to
the local Board of H Ah or other approving authority within 14 days from the pump"date i�
s000rdanoe with 310 CIWIR 16.351. j
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A. Facility Information ;
ON mwlayeo uu, 1. Syaem Localli n:
i, tabs (0o Pafi\ Ul Ul`L' L-:
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owiaor not /MNMs�s .Q/� 1�T 0/+����c�1 tlf
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2. System Owner: !
Z
Nan�s ;
Address(N dI fMaM ftm bootlon)
CWTown stab zip Cods
Telephone htrrmber j
j B. Pumping Record
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1. Date of Pumping 2. Quantity Purnped: Galcm
3. Component: ❑ Cesepocl(s) ❑'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(desaft):
4. Effktent Tee Filter present? ❑ Yes ❑ No if yes,was it deaned? [� Yes ❑
i S. ObeervaSd condition of oomponent pixnped:
i
I -
i 6. System Pumped By.
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Whlcb i.ioarhe NNMnbe;,
COMPIM
7. Location whero ca Is to were disposed:
Slipufte of akWW Dale
SWohm of Rsoshritq FooNNY(or M NA*ftdWY nscW) Dale
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t6blr Wjw 1U12 Svistem Pumoina Record-Pans 1 of 1
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