HomeMy WebLinkAboutSeptic Pumping Slip - 100 GREAT POND ROAD 6/7/2018 Commonwealth of Massachusetts
CitylTown of �
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System Pumping Record 0 7 201f�
Form 4
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DEP has provided this form for use by local Boards of Health. 04 er 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 fora 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
I
Important:When
filling out forms 1. System Location.
on the computer, �`
use only the tab 01 ed poluA
key to move your Address
cursor-do not MA
use the return — ( ��� –.------ _
key. CitylTown State Zip Code
2. System Owne
Name / f
ream
Address(if different from loca#ion)
CitylTown State Zip Code '
-
' Telephone Number
B. Pumping Record
1. Date of Pumping Date — 2. Quantity Pumped: canons
3. Component: ❑ Cesspool(s) ie Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
i
6. System Pumped By:
Name Vehicle License Number
Stewart"s Septic 58 So. imball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradfo , M ,...__
Signatur uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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