HomeMy WebLinkAbout- Septic Pumping Slip - 54 LONG PASTURE ROAD 6/10/2019 Commonwealth of' Massachusetts
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System, Purhping, ca4
Form 4
DEP has provided this form for use by local Boards of Health. Otherforms may be, used, but the
information must be,substantially the same as that provided here. Before using this fora, check with your,
local Board of Health to determine the form they use The System Pimping Record must be submitted t
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIMR 15.351.
Facility Infor
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fi'lling out forms System Location:
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n the computer,
use only the tad "s
key to move your Address
cursor-do not No. And,lover MA 01845
use the return ,,., ..,. �.
r* pity/Town Busts Zip Code
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21- System Owner:
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Name
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Address if different from location)
City/Town State Zip Cod
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Telephone 1\.umb r
B, Plumpilng Record
1., Date of Pumping
t unt�t � rr� � Gallons
3. Component~ El C ss 1 s optic Tank El Tight Tank 0 Grease Tr w
E] Other (describe)*
4. Effluent Tee Filter rnt es El N o if yes, was it cleaned Yes No
5. Observed condition of component pumped:
1
. System l ' me
Ile
Name Vehicle License Number,
Stewart's Septic 58 S . 'Kimball Sit., Bradfoird,MA
Company,
'`. Location lire contents weredisposed:
20 S . Mill ,fit., Bradford, MA
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Signature, f Hauler Cate
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Signature of Receiving Facility or attach facility receipt) Date
t5f rrn *1 12 System Pumping Record Page I of