HomeMy WebLinkAbout- Septic Pumping Slip - 121 CAMPBELL ROAD 7/8/2019 ., uommonwealth Massachusetts
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System' --- � Pumping
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DES' has provided this form for use by local Boards of Health. er 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
the local Board of Health or other approving, authority within 14 days from the pu!mpling date,
accordance with 3,10 CMR 15.351.
A, Facility Information,
Important*.When
filling outforms 1, System, Location:
on the cornputier, .,
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use t h return City/Town, � .,� �,�.. �...rvmm���� Ott i Code
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2. System Owner:
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Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
Date Gallons
3. Component: El C s,,S l(s) Tank 0 TightTank Grease Trap
E] Other(describe)
4. Effluent Tee Filterpresent.? El Yes -'.No if yes, was it cleaned?
5. Observed condition of component pumped:
0
6 System Pumped By:
Name Vehicle License Number
Stewart's Septic 518 So. Kimball St., rafr ,f
Company
7. Location where contents were disposed':
20, So. Mile St., Rradford, MA
Sigoature of Hauler r Date
Signature of Receiving Facility r attach facility receipt) Date
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t5forrn4. . 11/12 System Plumping Record Pugs 1 of 1