Loading...
HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 100 WILLOW STREET 7/21/2022 >orn a arch. of massachusefts 1CIN71 ow Of 2at2DovE� toall jM z �©pea DEP has provided this€orm for use by local Boards d Health_Other forms may be used,butte infornation must be substan€Wly the same as that provided here.Bef-ore usirig th4s form,eheok vM YoI' local Board of Health is determine the form they use.The System Pumping record must be submi'resd b3' the local Board of HeMth or other approving authority WY in 14 days from the pumping dal in accordance v n 3*10 CMR i 5.35'i_ Imporcin�When - fi IIng outibi is 1. System Lgcatlorr. on the computer. 1 7 use only the�b CIO W L 4 I d l .t i key to move your Address - cilf-QOr-do Pat use the rcaim C��I-� i. — 6 513� �p�y ((By. I Syst"'B..m Owner Name Address{irriirrerantftam(oeaban) Gi;yT(avn sip Zip Code Telephone Number 1. Date of Pumping --y A 9 Dn�e �` 2. Quanj Pumped: Gallons 3_ Gomponenit [] Cesspool(s) ❑ Septic?anic ❑ TighiTank Grease Trap ❑ Other(describe): EffluentTes Filter present? ❑ YrrsO"7ND If yes,was it cleaned? ❑ Yes ❑ Ilo S. Observed condition Cf component pumped: 6- System Pumped ajr_ Name - Vehicle License Number GoMt"•J i Loon where caniQni' ere disposed: Sig auter Data 5ignaEur at i�eoeiving r'ec ity(of nueah recmy MGWPQ Data i5iartrsa.dec�'i 1!'12 SySL-M Pumping Remra-Page 1 of*'