HomeMy WebLinkAbout- Septic Pumping Slip - 851 JOHNSON STREET 12/12/2015 Commonwealth of Massachusetts
City/Town of Boxford
System Pumping Record
Form 4
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 310 CIVIR 15.351,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab __yr 4' t'v.s et,( . ......
key to move your Address
cursor-do not
Boxford MA
use the return --—---------
key. City/Town State Zip Code
2. System Owner:
VQ
Name
..........
Address(if different from location)
.............City/Town State Zip Code
—--------------------------
Telephone Number
B. Pumping Record
f r
1. Date of Pumping - I 01--fD ate 2. Quantity Pumped: Gallons
3. Component: F-1 Cesspool(s) E3--Septic Tank F-1 Tight Tank El Grease Trap
El Other(describe): ..........
4. Effluent Tee Filter present? E] Yes Q--N' o If yes, was it cleaned? El Yes UA/b
5. Observed condition of component pumprd:
—----........
6. Sy tem Pumped By:
Name Vehicle License Number
Ste .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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