HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 458 FOSTER STREET 2/3/2022 RECEIVEC,
Commonwealth of Massachusetts
City/Town of FEB 0 3 2022
System Pumping Record TOWN c�F NORTH ANDUVEF
r Form 4 HEALTH DEPARTMENT
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: qE8
on the computer,
use only the tab -
key to move your Address
cursor-do not j _ MA
use the return City/Town State Zip Code
key.
2. System Owne
Name
nvn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da 2. 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:
Jc Ct�- i V� Sei� �J1 Tory.
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
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