HomeMy WebLinkAboutSeptic Pumping Slip - 361 CHICKERING ROAD 6/27/2016 Commonwealth of Massachusetts
RECEIVED
City/Town of V",
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System Pumping Record
fForm 4
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DEP has provided this form for use by local Boards of Health. Other forms may be useI", ut the
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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 farms 1. System OCatlgn:
on the computer, (J�
use only the tab ------ –
-- -
key to move your Address
cursor-do not
use the return --
key. City/Town State Zip Code
2. System Owner:
Name —_
rerom
------- -- — ---------
.._
Address(if different from location)
---- ------- _.
City/Town State Zip Code
Telephone Number
B. Pumping ecor
1. Date of Pumping Date— .� `"---- 2. Quantity Pumped: G __.- --
allons
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 &2No
5. Condition of System: fv
6. System Pumped By;
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where canter s were epos
Stewarts Pre tr P.I. o Mill Bradford Ma 01835
Signature of Haul Gate
Signature of Receiving acility Date
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