HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 3/12/2018 1L""\ Commonwealth of Massachusetts ID
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System Pumping Record t
Form 4nm
DEP has provided this form for use by local Boards of Health. Other forms may-i"secl, 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not MA
use the return ............
key. CityfTown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
..........--------...........................------
Telephone Number
B. Pumping Record
1. Date of Pumping 2, Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) 0 Septic Tank El Tight Tank El Grease Trap
El Other(describe): .............
4. Effluent Tee Filter present? El Yes El No If yes, was it cleaned? ❑ Yes El No
5. Observed condition of component pumped:
6. System Pumped By:
............
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
– ---—---------
..................
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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