HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 46 OXBOW CIRCLE 11/8/2021 Commonwealth of Massachusetts
City/Town of o w
System Pumping Record
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 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: Y
on the computer, O/� /�,
use only the tab ___ — _�j W, 'r —
key to move your Ad s
cursor-do not F [1Az'oo MA
use the return ty/Town State Zip Code
key.
2. System Owner:
�I Name
,earn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 66
J
1. Date of Pumping Date J Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
LA
6. SystemPumped By:
Nam 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
ature of HATer Date
Signature of Receiving Facility(or attach facility receipt) Date
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