HomeMy WebLinkAbout- Septic Pumping Slip - 21 CLARK STREET 8/11/2020 DECEIVED
Commonwealth of Massachusetts
City/Town of /1 / l Al dntzv-
o
System Pumping
Record � s�
Form 4
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 aof Health to nd of Health orermine the other pproorm vi aphey use. The System proving within 14 days fromg Record must e he pumping datubmitted to
e i
n
the local Bo
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:on the computer, Z
use only the tab
key to move your Address
cursor-do not City/Town MA
use the return State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
. -162 4-/�
1. Date of Pumping Date . Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [g-15ro— If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compon t pumped:
6. System Pu ped By:
Vehicle License Number
Name
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill rad rd, MA
Sign re of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5forrn4.doc•11112 System Pumping Record•Page 1 of 1