HomeMy WebLinkAbout- Septic Pumping Slip - 60 ROCKY BROOK ROAD 5/8/2019 Commonwealth olf Massachusetts
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Form 4
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DEP has provided this form for use by, local 'Boards of H'ealtll Other forms may be used, but the
%nf rm,ati n must be.substantially the same s that provided hpere. Before using this form,, check with your
local Board of Health to,determine the form they use. T'heSystern Purnping Record must be submitted t
the local Board �f'Health or othier approving authority within in fern t� ate i
t
eons with 310 CM R 11 5.35 .
A. Facility Infor
Important:When
filling out forms 1. System Location:
on the computer,
use only the,tab
key to rove your Address
m
cursor-do not �� nw�use the rt�urnM
....�
key. City/Town State _ Zip Code
V 2. System Owner:
Name
Address if different from location)
City/Town State dip Code
.mm mm.m .....
elephon G�lumbl r
B. Pumping
0
®Date T �.
�M Date of Pumping �� �,.mm.��. . Quantity ��
ale
Gallons
3. Component El Cesspool(s) ;peptic Tank EI Tig t n Gro, se' ra
El Other(describe);
mm wwrwrmmm nuu r
mmmmmmmmmrmm mrw�mm m rruwvww
4., Effluent Teo, Filter present? D Yes J
If yes,, was it cleaned Ej Yes 0, No
5, Observed condition of component rn ed
6* Systemil Pumped Bye
Name Vehicle License umbe �...,
Stewart's Seep c 518 So. Kimball St., Bradford,
Company
. Location where contents were disposed
20 So. Midi St, Bradford, MA
w
r '
ire ofHuir Date
Signature
Receiving inFacility nr;���.,,,,attach facility..
receipt) Date
t f rm,4.d ,,11/12 Systern Pumping Record Page I of I