HomeMy WebLinkAboutSeptic Pumping Slip - 82 BEAVER BROOK ROAD 12/18/2015 Infofmation P has pr this form for a by 1 Boards of Healtili
h the same as ow pmvidw Other forms maY be used, but the
local Board of Hems to determine the form they use.The g ' .00**UWnV this&M,Check With your
the local Board of Heialth or other approving u in Oda Pum rd must be submitted to
accordance Mt h 310 R 15.351. n!PM9
date in
A. Facility Information
Important n
. nuns out 1. System Location: l
use o UN bb
),3 e° v e r caa �. � 7
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key to move your A,ddrosa
cursor•do not / /j y
Us8 t4o MtUM J CI /' ✓�G C/ v( ✓' d 1
key. CdyRown
y
2. System Owner.
_f 6 M r �,
Addroot(d diKinnt Ilan n)
Cityf own
Zip Cado
T Humor
D. Pumping Record
I. Date of
wa►Pumping
_ Y -
P 9 2. quantity Pumped:
Gouons
3. Type of system: ❑ Cesspool(s) Septic Tank T' ht Tank
� ❑ Grease Trap
Other(d be):
4. Effluent Tea Filter present? (j Yes PYNo if yes,was it cleaned? Yes ❑ No
5. -Condition of System:
6. System Pumped By:
tdomo , Y V "license r
Company
7. LOcatiOn where contents were dlepo :
LS
lure of Hiular pars
Signatum of RaWng Fatality
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1510mi4.dw 0
System pumping Record-Page i of i
I
f FORM 4 - SYSTEM PUMTLNG RECORD
Massachusetts
Commonwealth of
M a s
�•��x �� �� t �-'►'`h, sachusetts
in Record
System Pumping
5vste n weer
C.r
ystem ocation
I
r '
r l
Tape Emergency ❑ Routine
Cessp, )I: No ❑
Yes ❑ Suptic Tank: No ❑ Yes
6 "0 _ gallons
Pumping: Quantir\ Pumped:
Date (
r�YL ' C d��`,. . Permit #:
S\ster.. Pumped by (Company): �'7.... �---�--
Conte .ts transferred to:
Cont , s disposed at:
`— -- i amre
D t� )� .. Pumper S gn
Cone ition of systemiother comments:
l
D£.P A.PPROVED MW'i • 1«/07/95
i
TOWN OF NORTH
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
upt&( (example: left front of house)
DATE OF PUMPING: t� ® QUANTITY PUMPED I GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO S
NATURE OF SERVICE: ROUTINE-� EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: