HomeMy WebLinkAboutSeptic Pumping Slip - 951 FOREST STREET 5/12/2016 Commonwealth of Massach Ott
City/Town of
A/o, arv'�P[,
I 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. &,!fore 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System o tion:
on the computer, e,
use only the tab
key to move your Add
cursor-do not /.. w �
use the return -C
key, I y own State Zip Code
2. System Owner:
Name
tetum
Address(if different from location)
---------------- -
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) >L-,Septic Tank F-1 Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes/kTNo ,
5. Condition of System:
6. System Pumped By:
Name Vehicie 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 Date
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