HomeMy WebLinkAboutSeptic Pumping Slip - 65 SPRING HILL ROAD 1/11/2016 ^ -
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Commonwealth of Ma,8 ar6@
City/Town of North mm
o /er
System Pumping� Record '
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may beused,"b'u1he information must be substantially the same as that provided here. Before using this form, check
with yo
local Board of Health to determine the form they use. The System Pumping Record must be submitted
the local Board of Health or other approving authnhtyvithin --ys from the pumping date in
accordance with 810ChR15.351.
A. |
Facility '-'_'.,.~^^.~^"
Important:When
filling out forms 1 System Location:
on the computer, �r/
�eun��e�b ��\ k \ �6�
key to move your Address U±
cursor-domot
North use the�m
key. City/Town ��---- ---__.�_ � _ _________ ____
� 3m�
2. Owner:
"x"=z« &
mame / �- ----' -----------------
Address(if different from Tooatinn _--------' —' --- --''-'----------'----'
oty[Town ���-'----------- -- �
-- —_ Zip Code
Telephone Number
B. Pumping Record
�
1. Date ofPumping ---����/�~_�—� _ 2� Quantity Gallons Date 3. Type ofsystem: Ceaupoobd Septic Tank 0 Tight Tank Fl Grease Trap
0 Other(describe).- -----'---\ _`-�_--___---------''—'---'-- -
4. Effluent Tee Filter present? Yes No If yes, was vcl'eaoed? D Yes [I No
5. Condition ofSystem:
h. System Pumped By:
Stewart's Septic Service-- ` veoicle License Number -- '
Company �------' '-- --
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
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c��-----'--' ----
x�nawreofReoe�nO —'----- '----'-
�on-nw�c.03/06
System Pumping Record-Page I of 1