HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 366 FOREST STREET 2/6/2024 �LN Commonwealth of Massachusetts
City/Town of
° System Pumping Record
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: T°wn
on the computer, a- °�"ol(h
use only the tab o n n,,
key to move your A �s) �T
cursor-do not l v % MA
use the return Fin
City/Town State O 6 flee pde
key. 4
t� 2. System Owner.
Same `S �� �+�� Lot
Name
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 6 �;?
1. Date of Pumping Date Gallons
2. Quantity Pumped:
i
3. Component: ❑ Cesspool(s) X
Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): /
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes No
5. Observed co ition o� ent pumped:
All of this estimated
informat n is on-bindin , valid only at the time of pumping. Not responsible beyond the date above.
6. Syste�"umpe q By: J ,
Name Vehicle License Number
Company
7. Location where contents were disposed:
a`ar s Recelvin 20 So. Mill St., Bradford, MA 01835
See above
ature of Date
Signature of Receiving Facility(or attach facility receipt) Date
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