HomeMy WebLinkAboutSeptic Pumping Slip - 315 SOUTH BRADFORD STREET 1/1/2014 Commonwealth of Massachusetts
-- City/Town of
_ = System Pumping Record
Farm 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 form, 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: qtr u a
When ruing out 1. System Location:
forms on the
computer,use - — _ - -- - - ----- k ., -----...--- --.
only the tab r �
cursor o move
not
y Ad less
ve
use the return CitylTown State Zip Code
key. 2. System Owner:
V Q � 1 t'C ( o"�" ------ --- ---- ------
Name ------- _..._
Address(if different from location)
UU
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da e --- 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- ..-- --— .--- ------ — --- --
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes [�rNo
5. Condition of System:
6, System P mped By:
Name j+ q Vehicle License Number
Company
7. Location where contents were disposed:
- - — --------------
- � a
r" f
Date --- -- -- ----�-
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts Form 4 System Pumping Record
WASSM hUSE,'"I'tS
SYS-feM PLIMPing Record
....... ............... .......
System Owner System Lpcatjon
t r
Type: Emergency Routine
Cesspool: No
es /d*d:brTank: No Y's
Bate of Pumping; Quantity Puinped:_ Gallons
T
System Pumped By: Wind River Environmental,U.0 Permit#:
Contents Transferred to:
.................
Contents Disposed at:
015
bate: Pumper Signature: ...........
Condition of System/Other Comments ------
————------
..........
................ ..........
...........
bep Approved Form-12/07/95