HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 27 BOXFORD STREET 5/6/2024 Commonwealth of.Massacl � paa �,n�ov�t
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City/To�n of LL�-uevl
System Pumping Record MAY 0 6 2024
FoirM 4
DEP Hasthis Harm 18e b e�}at'� rent
lnfonrlocal Boatdut the
Zled
e s "thesamea that of Health. Other WMIded hem. remay beusedthisour
the kxi11 �of F �debnrur►e the form trey use. The,
usingform,check with
accordanceg Record
IWHI310 CMR 15.351.or other aPProving authority wthin 14 days from must be submitted to
Pumping date in
A. Fac i ll1iy Information
M ,t fa
orms 1. system I ocadon:
as w-do net s
w.Ow re „r, _--�
WY. mown
2. Syebm state
ZJp Coda
�ddrose(if tbm
57_ own
ztp Code
B. Putnpil�g Record rebPhorte Number
1 Dab of Pumpin8 (,` a
tom,
2. quantity pumped:
3 Component: ❑ Cesspooi(s) ❑ Septc Tank
cauons
. ❑ Daher� �:
❑ 7`ght Tank ❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes ,❑ No If ye8,was
5. Observed of componen �ed:
t It cleaned? ❑ Yes ❑ No
Purfy
6. Sysfe�n �.
NAM -
CompAny VblNcls Uoems Number
7. Low bents were disposed:
S
Saratur,�or- FacWy(a temd,tom►Nos" t�
doe 11/12 i
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