HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 700 MIDDLETON STREET 6/5/2026 << C;ormonwaltf7 of rv1 �ssct^�t_aE tts Town of IVOrthAndVel"
Ity��� own CST
stem Pu lr
P y 7 c� F c c�r c� JUN 15 2m
y Form 4
(7E F' has provided this forrn for use by local Boord(, of P1ea th Other for y o
pa
t
nforrr�atlon must be substantially ti�e, t arns a, that providedhere.. Before using this fbrr1T cl)0 '�l H-t your
local Board of Health to determine the form Ihcy use, -1 fjo System Purr)pinq Record must be subrnitte;d Io
the local Board of Health or other approving sulho(ity within 14 days from they pumping Gate In
accordance with 310 C M R 15,35'I __--
__.__ __--..-. ---_ .._ H1")L)S f- fIc rt b ck sIrle re7r el' rIpht
A. Facility Infort at'lot1 C3UIl_C)ING front `idrr f e i i Ve,f't ii(,ht
Important:When DECK: un(:fer
(Illincr ou( form' 1. Syst(,n) I...ocation
on(he computer,
r wdy the tab
u y to move,your Addr a
uSP,( r -(10 nr,>I �I ll"ow/pr� Vl,r�, p ,-f
o.r e lire: rcalurn .._. ".._°....,� ....... ,_ .__..__ ..._...... _, _.._...__ _ _.__ .. ...__..._ _._,_��_1 ._ S
hog `✓ a ,Irate 7.irJ Code _
�F---- 2. Sys tern ra
�lwec
J r ame
uro /�
Acldr f dufterend trout IocaU(an) __...-_...__
MA
Ci(y/Town ___.. - _ -.._.. _... - _.. ------ _
_._
?ip Code
TrlcrJftor'u: Numfar7
------ r
- ---,,..
PI IMI)ir7g Record
1. Date of Pumping �°-"- .-" , A c
Dale 2. Quantity r urnpe.,d __-_
Gallons
3. Cor-nponent: (_ C'eshpool(st) Septic Tank -Tigr)l Tank (.] Crerasr. trap
Other (describe).
4. Effluent Tee filter re�ser-ft?
P _1 Y"- )__) No If yes?s, -as it cleaned Yes
5. Observed condition of cor-(portent pu nped.
6, `3ystern Pt,j 7ped By:
Dave T_Iriy___._._ _.__ _ . ..._-_ ___ M Is5 1l AU t Mass 1 F D31I
Vta,til(lln E_iCe;n�;w N r7her
eakeson Enferprises_ Inc
Company _.. .
7 ( ")lion where cont(-,nls vv�;(�r�� (aispoSf;O.
GLS
Si'nalta of Hauler
)ttic ,
Sipnaftirr, of FtiFceivinsl I nrality (oi allar h (F r)71c- --
l5(orrnkdoc, 11('11 Sys e fn Pumping Rpc:rard Page 1 or t