HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 733 TURNPIKE STREET 3/15/2022 Commonwealth of Massachusetts �c�wE�
City/Town of o &do vc4 loZ2
System Pumping Record BAR 15 PN0pVEK
Form 4 WN OF NIDVNRklMEN
T T
M PLlND
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, •'—'7 3-3
use only the tab /�� (
key to move your Add:T
cursor-do not �JU2y
use the return Cityfrown / State Zip Code
key. i
r� 2. System Owner: �2 U14
�I Name
renm
Address(if different from location)
MA
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ate 2. Quantity Pumped: 3Q�
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:
56/1 d�T�/Yt
6. System Pumped By:
/1017, h
Name V Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradfor
at ure Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
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