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HomeMy WebLinkAbout- Septic Pumping Slip - 124 TUCKER FARM ROAD 1/22/2019 Commonwealth of Massachusetts µ. City/Town of System. Pumping Record `4, Form 4 ,� .�w 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 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location. on the computer, { use only the tab �t� key to move your Address cursor-do not ( MA 01985 use the return --..._...�.ww — _........ ......... ._......_... — .... .. ....... .......... key. City/Town State Zip Code 2. System Owner: reb Name � n Address(if different from location) ......................... City/Town State Zip Code Telephone Number _.............................. �. _._. B. Pumping Record r 1. Date of Pumping rr r �l 2. Quantity Pumped: - Date Gallons 3. Component: © Cesspool(s) 0eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 6o If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of compopent umped: 6, Sys m Pumped By: ame Vehicle License Number Stewart's Septic 58 8 . Kimball St., Bradford,MA Company 7. Location where contents were disposed: 0 So. Mill radford, .w.__.� . ...._�._..._ r ignature of 11.6ler Date __—.. ....._......... _ —_._. ..... Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record-Page 1 of 1