HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 926 FOREST STREET 10/4/2023 Commonwealth of Massachusetts
_ Commonw
City/Town of No.And wer
W System Pumping Record
Form 4
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
g Record must e
local lBoard of Health to
Board of Health orermine the other approving ngrm they use. The System au authority within 14 days from
nm he pumping datubmitted to
e I n
the locaca
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab Address
key to move your _
cursor-do not Zip Code
use the return City/Town State
key.
2. System Owner: `
tab
Name
rsrtm
Address(if different from location)
No.Andover MA
State Zip Code
City/Town
Telephone Number
B. Pumping Record )00
��1. Date of Pumping Date 2. Quantity Pumped: Gallons
)
3. Component: s Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Cesspool(s)ool p (
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �o If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So-Mill St.,Bradford,MA q/ /// 23
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
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