HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 116 BRADFORD STREET 3/15/2022 Commonwealth of Massachusetts $ECEtvEL
City/Town of (dOWA MAR 15 2022
System Pumping Record
Form 4 TOWN OF DEPARTMN'T
GM E
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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, I j BCA
use only the tab (�
key to more your Address
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
f� /�
(p
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D e 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 compopent pumped:
6. System mped 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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