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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 CANDLESTICK ROAD 4/2/2024 Commonwealth of Massachusetts City/Town of -/ /o /jLLd-E'G,-e, I System Pumping Record Form 4 ^,r)R 2 2024 GSM 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, �v,� i CK use only the tab % (/ key to move your Address cursor-do not IV d ,V-ei- MA _ use the return City/Town State Zip Code key. 2. System Owner: rah Same Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Da 2. Quantity Pumped: cal ns 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - - — 4. Effluent Tee Filter present? ❑ Yes NoIf yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of co pumped: © All of this estimated information is -binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Syste p d By: Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Fac y,20 So. Mill St., Bradford, MA See above Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1