HomeMy WebLinkAboutSeptic Pumping Slip - 45 INNIS STREET 7/15/2016 Commonwealth of 10a 6 cp h L I S 1�,t 1:SS,
City/Town of A/0 n c) 6 ve- v--,
Systern Flumping Record AUG U
-,.TL�Pm1v F,w Form 4 C"r �co V
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 Systern Purn ping Record must be submitted to
the local Board of Health or other approving authority within 14(lays from the pumping date in
accordance with 310 CIVIR 15.351,
A. FacHity Wormation
Important:When
filling out forms 1. Systea Locatinn,
an the romputer,
use only the tab nan-
key to move your Address
cursor-do not 0 .� A c! o ve
use the return
key. Cityfrown State Zip Code
2. System Owner:
M f
Pw—ct
Name
-6s Address(if different from location)
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity PLIMI)ed:
Date Gallons
3. Type of system: F-1 Cesspool(s) 1: 4Septic Tank ❑ Tight Tank ❑ Grease,Trap
F-1 Other(describe): ---------------------------
4. Effluent Tee Filter present? El Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
6. Condition of System-
6. System Pumped By:
I (�q
Name Vehicle License Number
Stewart's Se tic Service
Company
7, Location where contents were disposed:
Stewart's Pre-treq-4r9nent P 0 I Bradford, Ma 018:35
Sig n aue Date
Signature of Receiving Facility Date
t5forn-14.doc-03106 System Pumping Record•Page I of 1