HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 5/8/2019 (9) ..:I Commonwealth of Massachusetts
v,;alsl Ir.^'V6.,,,..,/;d f V+fl/,✓ok��rlr
City/Town
U r 7'7'111"': 1
System Pumpiln,g Record
Form 4
r
.. (
r
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information rust be substantially the same as that provided here. Before using this form, check with your
local Beard of Health to determine the form they use. The System Pumping Ree r l rust be submitted fitted to
the Focal Beard of Health or ether,approving authority within 14 days from the pumping date in
1
accordance with 310 CIVIR 15.351.
A., Facility Information
lm rt urn�When
filling out,forms 1. System oc ti n:
on the computer,
use only the tad 5
key to move your Address
cursor- not
returnale. veer
MA C)1845
use theCity/Town to Zip Code
2. System Owner.,
Name
rr
Address if different from 1tirr
City/Town
Zip Cade
Telephone Number
B., Pumping
1
. Date of Pumping
�� Quantity Pumped:
Cate Gallons
I Component: El Cesspool(s) E] Septic Tare Ej
ED/16ther(describle):
. Effl ent Tee Filter present? El Yes I 'yes' was it cleaned? Yes No
5. Observed condition of component pumped,
,f
6. System u mpl B
Name Vehicle License Number
m r
tew r.rt s qqp�fic 58 So. Kimball St., Bra ord,MA
Company
. Location where contents were disposed:
20 S . Mill St,, Bradford,
V,
Sign Date
Signature of Receiving Facility(or attach facility,receipt) Date
t forma , o 1 1 12 System Purnping Record P- 1 of 1