HomeMy WebLinkAboutTavern on High - Grease Trap - Septic Pumping Slip - 18 HIGH STREET 5/2/2023 Commonwealth of Massachusetts RECEIVED
F W City/Town of
System Pumping Record �9P.Y o 22023
s TOWN OF NORTH AKIIOV'F
Form 4 HEALTH DEPART-41101sr
,
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 Q
use only the tab (�
td, _-5
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner: t
tab
Name
nam
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank it Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
oza\� Q -
6. Sy5te
nPumRed 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
Same day
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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