HomeMy WebLinkAboutSeptic Pumping Slip - 19 BRADFORD STREET 12/12/2017 /
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-i DEP/�,RTNAENT
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 y(
local Board of Health to determine the form they use. The System Pumping Record must be submitted
-the local Board of Health or other approving authority Within 14 days from the pumping date in
accordance with 310 CMR 15.351.
_ Facility Information_
'
. ` . When'
filling out formg , I System Location:
on the computer,
key~move`your Address -
cursor-do not
use the return Cfty/Town State Zip Code
Address(K different from location)
' City/Town
^
. Telephone_--Number
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1. Date pfPumping 2Quantity Pumped:
Uate Gallons
' ~` C~'r~ ~~'~ ~~~~r~~°, ^~ --,-- '—'' R Tight T-- ^~ Grease Trap
. . .
EJ Other(describe):
/L Effluent Tee Filter present? [] Yes L9~No If yes, was it cleaned? FJ Yes S—No
5. Observed condition of co t ped:
8. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location_where contents were disposed:
20 so mill st bradford ma
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Signature oHauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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t5form4.doc-11/12 System Pumping Record-Page I
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