HomeMy WebLinkAboutSeptic Pumping Slip - 73 RIVERVIEW STREET 12/8/2016 �
Commonwealth n� K�Massachusetts
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System Pumping �� �
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Form 4
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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 31UCK4Fl15.351.
A. Facility Information
Important:When
filling out h,nno 1. System U --
un the computer,
use only the tab
key k,move your *du
cursor'uonot
use the return
key. _`,'..... State_ Zip Code
2. System Owner:
VQ
me
Address(if different from location)
Qhlrfmwn State Zip Code
B. Pumping Record
1. Date of Pumpin8 tib/ Pumped:
Date s
3. Component: [l Cesspool(s) nk El Tight Tank Fl Grease Trap
�1
Other(describe):
4. Effluent Tee Filter present? E] Yes 6' No If yes, was it cleaned? U Yes U No
5. Observed condition ofcom nent pumped:
(9;-0
-. -'_
Name Vehicle License Number
Stewarts Septic_58_So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st br dford ma
le
ignature of Haule Date
S ign eceiving Facility(or attach facility receipt) Date
ignature of
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t5forrn4.doc-11/12 System Pumping Record