HomeMy WebLinkAbout- Septic Pumping Slip - 357 CANDLESTICK ROAD 1/6/2021 City/Town of 'ar
aw Comnionwealth of Massachusetts
r) 0 V ejo-
System
fCd kN �
a tl w Purniping
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 seals as that provided here. Before using this form, cheek with your
local Beard of health to determine the form they use. The System Pumping Rec- rd lust be submitted to
the local Board of health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Informatu"on
Important:When
filling out forms '1. Systelm Location:
on t�l computer, � ��
useonly the tab .� ��..,�..� ... _a_..._..�
key to move your Address
cur er-do not
use the return
keys, City/Town State Zip Code
e
2.. System
Owner.-
Name
Addre:s(f different from location)
State Zip Code
TE!Ie hone Number
B. Purnping Record
1. bete of Pumping _ 2Quantity Pumped: Gall_._.. on
3. Component- es<,pool(s) Septic Tank El Tight Tank grease Trap
l Other(describe): ._.........
.._.. .._... _..r_.....___.... _ ..... ...._...
4. Effluent Tee Filter present? [I Yes o If yes, was it cleaned Yes E] No
5. Observed condition of c..cmponent pumped:
6. Systelm Pumped y:
t _ ._...
Name �.w..... .� .._.._... _ �._ _.._ .�. __.... .��,..... .� ._.._..�.� . Vehicle License Number
Comptiny
. Location where car" i ll"W� df d.
i nature of Receiving Facility._cr �. .,mm_�.�._..__...�. .�.._..._�.. ��._�....�.�.,_�..._._ . .,.�...._. .....��_w�..__��..__ ..�..M_._�.....�.W.._._.�._..�.._���...__, .. ..mm.._.....�� ....�._�...�._.�,....�..___..�... �..�_..._.....
( attach facility receipt) Date
t5furr 4.dcc*11/12 `yster" 'um ping record•Page 1 of 1