HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 566 FOREST STREET 12/11/2023 Commonwealth of Massachusetts
m p City/Town of
° System Pumping Record
OEC 112023
r` Form 4
M
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, c /
use only the tab 15 lY �d r�� * ��
key to move your Alps
cursor-do not 01't� A t l-On MA
use the return
key. City/Town State Zip Code
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2. System Owner:
Same S V e- V V__
Name —
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record `
1. Date of Pumping D e 2. Quantity Pumped: Gallons
l d� 0 -
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.
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Sy em Pumped
- - a
Name Vehicle Li cen a Number
Company
7. Location where contents were disposed:
Stewart's Receiving Facie, 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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