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HomeMy WebLinkAboutPump Chamber to Town - Septic Pumping Slip - 370 GREAT POND ROAD 6/20/2020 Commonwealth of Massachusetts RECEDED w City/Town of System Pumping Record DER Form 4 TO�THpEpARTM M 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. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: �� ao'e on the computer, use only the tab r key to move your Address cursor-do not MA use the return City/Town State Zip Code key. 2. System Owner: Name — rerun Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping `�— 2. Quantity Pumped: �000 — Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): PG — 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. Mill St., Bradford, MA Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1