HomeMy WebLinkAboutSludge Tank - Septic Pumping Slip - 351 WILLOW STREET 7/8/2019 4
WU0
Common ^rflth, of Massachusett,s li
'ityffowni of' No. An vw
n
System Pump"Ing, Record'
I 111111 1") V'E R TIN,Of:
Form 4
TM
DEP has provided this form for use by local Boards of Health. Other 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. Tide System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the purnping date in
accordance with 310: CM R 5.351
A. Facifity Information
Important:When
filling out forms 1. System Location,
on the computer,
use only thie tab Vvi
key to move yoluir Address
cursor-,do not, N . Andover MA 018,45
use the return, ..............
City/Town State, Zip Code
key.
2. System Owner.
tab
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
e� azry
6
1. Date of Pumping Date 2. Quantity Pumped: Gallons
0 36. Co,nllonent*. El Cesspool(s) Eeptic Tank [:1 Tight Tank E] Grease,Trap r)
Other,(describe):
4. Effluent Tee Filter present? E] Yes 'N co If yes, was it cleaned9 Yes No
5. Observed condition of omponen,t pumpled:
/J
6. Sys t 'umpe
r
ell
. ..........Name Vehicle,License Number
Stewart's Sqp i � I Kimball St., Bradford,MA
Company
7. Location where! contents were disposed:
,2 So. Mill S Bf dford MA
2 B,� d
A
S" nature of Hauler Date
S s ig
ign ature of Receiving Facility(or attach facility receipt It
t5form4.doc* 11/1:2 System Pumping Record Page!1 of 1