HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 18 HIGH STREET 12/11/2023 IL
Commonwealth pf M s achusetts
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W° System Pumping Record ` �12023
Form 4 �E
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: 5
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return MA
key. City/Town State Zip Code
2. System Owner:
Same
Name Tws-cn (in
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 1. Date of Pumping
61 _
Date Gallons
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 component pumped:
'zav W Lazzis All of this estimated
information is non-binqoivalid only at the time of pumping. Not responsible beyond the date above.
6. System P ped y:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receivinq_Facility, 20 So. Mill St, Bradford, MA 01835
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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