HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 3/16/2017|
| Commonwealth pfMassachusetts RECEIVED
r,
��/^ v ��««/ / ^//�
�� ��/ �6�
Pumping
Record
'^""
System . ������� x����n �
—
Form 4 �J�N��NOFTHANDOVER
� HDEP*RTMEMT
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 ofHealth orother approving authority within 14days from the pumping date in
accordance with 310 CyWR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
onthe computer,
use only the tab -
key tomove your Address
vvmur-vono^ ov
use the return
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
city[/own State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping2� Quantity Pumped:
DateGallons
3. Component: Fl Cesspool(s) [l Septic Tank [l Tight Tak El Grease Trap
13 Other(describe): ��~�/�`��' ----- ---------
4. Effluent Tee Filter present? Fl Yes [| No If yes, was it cleaned? Yes Fl No
5. Observed ondition of componentpumped:
\ \— � -------------------- ------
Stewarts Septic 58 So Kimball-St Bradford Ma
Company
r P
7. Location where contents were disposed:
��ture-�auler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.uuo`11/12 System Pumping Record~Page 1of1