HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 4/3/2013 Commonwealth f asp chin tt
-- C ity/�T wn of o . +y)� J
System Pumping Record
- —
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used but the'
information must be substantially the same as that provided here. Before using this farm, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to mays your Address -----
cursor-do not NewbU
use the return – ry---- _ __—_—_ — Ma
City/Town/Yawn - ---- -----— -- ----
- -----------------------
I<ey. y State Zip Gode
y
2. System Owner:
Name � --�,.� �_ ----- - - — --- ------ - ------
(eta
Address(if different from location) --
Newbury
----— -------------------------------
City/Town State - ---- — Zip Code -- —
Telephone Number ---- - — --- ---
Pumping r ,e
..
1. Date of Pumping —bate -`- 2. Quantity Pumped: — --
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank [ Grease Trap
❑ Other (describe): -- --- ' _ "
4. Effluent Tee (=filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number --
Stewart's Septic Service___
Company - — --- ..
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date — --
Signature of Receiving Facility --_ -- pate--- — — - --
t5form4.doc>03/06 System Pumping Record>Page 1 of 1