HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 466 WINTER STREET 11/8/2021 Commonwealth pf M ssachusetts
W City/Town of /O 0
U14
System Pumping Record
Form 4
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:
on the computer, !, /
use only the tab J
key to move your Ad r s a
cursor-do not MA
use the return City
key. n State Zip Code
2. System Owner:
rab
Name -- --- -
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date �SepticTaunk
ntity Pumped: Gaiio3. Component: ❑ Cesspool(s) El Tight Tank ❑ Grease Trap
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compon pumped:
6. Sys mped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were osed:
0 S . Mill St., B dfor - A
.4 Z5���`�/
nature of Date
Signature eceiving Facility(or attach facility receipt) Date
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