HomeMy WebLinkAboutSeptic Pumping Slip - 1360 SALEM STREET 3/23/2016 ---- Commonwealth of Massachusetts I 'r r CEWED
q - ........
City/Town of
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 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 CM R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab _ _ -.
key to move your Add
cursor-do not
use the return (-�-------
S t
key. City/Town Zip Code
VQ 2. System Owner: (7
Name
Islam
Address(if different from location)
——--------------- ------
City/Town State Zip Code
Telephone Number
B. Pumping Record
0�0
1. Date of Pumping Date�'-3- 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 111 Septic Tank F-1 Tight Tank ❑ Grease Trap
F-1 Other(describe): —------------------- —-----
4. Effluent Tee Filter present'"r' ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
-—-—----------------
6. System Pumped By:
----------I-------
Name Vehicle License Number
Stewart's Se Service
019
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 Date
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