HomeMy WebLinkAboutSeptic Pumping Slip - 1801 TURNPIKE STREET 5/2/2016 « C,Or�rrr��rtr�r��l�h Of Massachusetts
City[Tow n Of i
System Purriping Record ' ft
Form 4
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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 -- --
Im�>orfant. __
forms on the se 1.S stem Location.-
When filling out Y
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only the tab key Address
to clove your /Ise✓t✓ �V
cursor-donol ✓ UtCt Y� :. - ... .. _.. _.. 6 - J S__._. _
use the return CityfTown Slate Zip Code
key. 2. System Owner:
Name
Address(it different from location)
City/Town St e Zip Code
Te epho Number
Record. Pumping Record
--- - --- ---- —_
1. Date of Pumping C7ate = - 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,
Ale, ---- _ ---
Name pp Vehicle License Number
Company
7. Location where contents were disposed:
j E M',i 7q SEPTIC- ENV! _
Signature o f Hauler BRADFORD, MA®1 to
7-6-07.2-' .._..._._
Signature of Receiving Facilit Date
15forrn4,doc•03!06 System Pumping Record-Page i of 1