HomeMy WebLinkAboutSeptic Pumping Slip - 373 RALEIGH TAVERN LANE 7/20/2016 Commonwealth of Massachusetts
City/Town of /VC) , 4Y)0j0Ve-am'
A,
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. 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 C M R 15.351.
A. Facility Information
Important:When
filling out forms 1. System)-gr-Ay
on the computer,
use only the tab (-� I &I Ck Vif
key to move your Add ss
cursor-do not p_v
use the return TO . . n-
key. CityrT6wn State Zip Code
rye
2. System Owner: Fro,f ct t
Name
renrn
Address(if different from location)
City/Town f State Zip Code
Telephone Number
B. Pumping Record
71-
, 2--
1. Date of Pumping Date Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) M,86-ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): yJ�Y
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systerb:
6. System Pumped By:
Name 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 Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1