HomeMy WebLinkAboutSeptic Pumping Slip - 1794 SALEM STREET 5/11/2016 \ Commonwealth of Massaoh setts
City/Town of Aj pec el Vj.rj)
System u i n Record 41/At
- as
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may be used, bM4."�
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:When
filling out forms 1. System L tlon
on the computer,
use only the tab _ -
key to move your Address
cursor-do not
use the return °- f""J,q. —-----
key. City/Town State Zip Code
2. System Owner:
Name
serum w.w
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record -- ---
d �
1. Date of Pumping t.- t °— -- 2. Quantity Pumped:
Date 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:
Cj
- �`
6. System Pumped By:
'Name Vehicle License Number
Stewart's Septic Servic(Y
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature�f,.Haul'e"r _
Signature-of Receiving Facility e ,.,. —�~� Date
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