HomeMy WebLinkAbout- Septic Pumping Slip - 106 ROCKY BROOK ROAD 5/8/2019 kY"'ln JJ
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Form 4
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DEP has, provided this form for use by local Boards of health. Other forms may be used, but the
information must substantially the same s that provided here. Before sin his form e k wi r c
local Board Health,to determ,ine the form they use.. The System Pumping Record must be submitted t [
the local Board of Health or other approving authority within 14 days,from the rnpi date in
accordance with 310 CR 15.3511 p
t
A. Facility
Information
[mPortant:When
filling out forms 1. System Location:
on the corutr,
use only the tab,
key to move your Address
cursor-do not
845
use the return No. Andover MA
key
w
City/Town State Zip Code
2. System Owner,
1A
Name
t
Address if different from location),
tion
CMt /rwn State Zip Code
Telephone Number
GallonsB. Pumping Record
'001
1. Date of Pumping 2., Quantity Purnped:
Date
3. Component: C ss ] s Septic Tank El Tight Tani Grease Tr ,
Other (describe) T .m . n...,.,. .v _ � ..,..
. Effluent Tee Filter present? El Yes 0, No if yes, was it cleaned Yes N 1
5. Observed con iti n of componentpumped:
00,5Lej
6 System Pumped y;
6141
Name hi l License Number
Stewart's Septic 5,8 So. Kimball St. Bradford,MA
Company
. Location where contents were disposed.
20 S . Mill St., Eger , MA
Signiaturie of hauler Date
m.. ..,
,Signature of Receiving Facility
_ r attach facility receipt) Date
t5fo rm 4.d oc 11112 System Pumping Record Page 1 rat