HomeMy WebLinkAboutPump Chamber - Septic Pumping Slip - 1780 OSGOOD STREET 6/7/2022 Commonwealth of as ach s tt f� RECEIVED
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W° System Pumping Record JUN 0 7 2022
Form 4
TGNIN OF NORTH ANMDEONVER
DEP has provided this form for use by local Boards of Health. Other form jl`6 QTbut 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 LocatlQf�
on the computer, S�Iy
/v,
use only the tab _
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner: J P j�
l�1 1
Name —_
r�rm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date/ 6 � 2. Quantity Pumped: Gallo
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:
�Ydd N
6. System Pumped By:
'77. 0 O-YDn i/1
Name I Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradf
ign ure of auler Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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