HomeMy WebLinkAboutSeptic Pumping Slip - 759 DALE STREET 5/16/2016 Commonwealth of MassachLisetts
P8 C
City/Town of
System Pumping c r
Form 4
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DEP has provided this form for use by local hoards of Health. Other forms may be used, b019646 AIM
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 Location-,
on the computer, um
use only the tab
key to move your A ,re,,,s i
,ursor-;1a not - „m
use the return —
key. ity wh State Zip Code
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2. System Owner:
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Name
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Address(if different frorn location)
City/Town State Zip Code
...........----
Telephone Number
B. Pumping Record
1. Date of Pumping --- — 2. Quantity Pumped: -�
Doke t�ns
3. Type of system: ❑ Cesspool(s) Septic;Tank ❑ Might Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes , No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition System
6. Systelii Pyrn�ed By:
a Vehicle 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 Gate
Signature of Receiving Facility Date
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