HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 135 JOHNNY CAKE STREET 1/9/2024 Commonwealth of Massachusetts
City/Town of NO kIt-et o v-e-(1-
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
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, /rCw
use only the tab Jul
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
Same
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record ;
( Z -Z 7- Z3 ,� D-��
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Cq"S"'eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes allo if yes, was it cleaned? ❑ Yes El'-No
5. Observed condition of co ponent pumped:
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receiving 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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