HomeMy WebLinkAboutSeptic Pumping Slip - 515 BOSTON STREET 1/19/2016 .,
`
�
Commonwealth of Massachusetts
System City/Town of
����rnK�-ng Record ����Q�~�U� AK�������Y�U�
Form
- DEP has provided this form for use ' loca800rdoo/HeeKh. Otherformamaybauoed. buVhe
information must be substantially the same as that provided here. Before using this honn, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted {o
the local Board of Health or other approving authority within 14 days from the pumping dote in
accordance with 310CMR15.351. �
A. Facility information �
Men filling out 1. System Location:
forms onthe
computer,use __--'_ _'_z�`�_' _~ _- - -' --' -- ---------'�--- -
omy the tab ken --- s
to mu"-your
cursor do not ��� ��Cowo /
�ethe mmm -'�
key.
2. - �
--�--' -_ --�<�'��~�'�� \ _ _ ______ __-
Name
--' ------- - ---' -' - -- - ---- - -
Address(it different from location) '
----------- - -- ' - -' -- ��� -- -- ---- op7���--'
�4mvw _~
--- --- ---- - ----
Tci�poonvmum6o
B. Pumping Record
1 Date '--�--f--� �----- 2. Quantity Pumped: 7���s---- '
� ome
3. Type ofsystem: El Cesspool(s) Septic Tank Fl Tight Tank F] Grease Trap
[l Other(describe):
4� Effluent Tee Filter present? Yes No {f yes, was hcleaned? E_jYes EjNo
5. Condition ofSystem:
6. System Pumped By:
Wind River
,,°~�~~~`~~ ~~�'-------'-- �L_!'
-------'- - ��� ---- -- TW6��[���ewunbm
numo ~~~ °`��"����
-__-____~~~~~_��~_-,--__-____-
omnpany �
7. Location Vle disposed:
���' '--- °t��
Signature~ ~. �
____-_ _---_---_'-- - ___
����R��� �u� ��
. ..
15mon4.doc-03106 ov,�mpu�n�oneoom'pu� / o/1
|
.
/