HomeMy WebLinkAboutGrease Trap - 2 interior - Septic Pumping Slip - 18 HIGH STREET 4/2/2024 Commonwealths of assachusetts
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System Pumping Record
Form 4 ",°R 0 2 2024
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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, CI
use only the tab
key to move your Address Ij
cursor-do not MA
use the return cityrrown State Zip Code
key.
2. System Owner:
r� Same
Fla\(Eq- in 0 Htq' h
Name
ieNn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:' 61/
II n 70
Da Ga o s
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trpp
❑ Other(describe): -- — --- — --
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
H&�_v U VS 4i All of this estimated
information is no in , valid only at the time of pumping. Not responsible beyond the date above.
6. Syste mpe 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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