HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 39 DEER MEADOW ROAD 11/8/2021 Commonwealth of Mass chusetts
City/Town of
System Pu ping Re ord
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:
on the computer,
use only the tab
key to move your Address
cursor-do not MA
use the return City/Town
key. State Zip Code
2. System Owner:
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record �(
1. Date of Pumping
Date Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
9 El Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o
If yes, was it cleaned? El Yes ❑ No
5. Observed condition of component Pumped-
6. System P p dB
Nam
Stewart's Septic 58 So Kimball St., Bradford MA Vehicle License Number
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
�ou r
Date
Signature of Receiving Facil'ity(or attach facility receipt) Date
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