HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 757 FOREST STREET 6/4/2024 Commonwealth of Massachusetts Tuiv P. o f ', r,, n" ,o
City/Town of
System Pumping Record
Form 4 JUN 0 4 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,
use only the tab F66en
key to move your Addres
cursor-do not 'T MA 0
use the return CityrT�Ow A01 Ar
key. State Zip Code
r�
2. System Owner:
Same
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallo
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 21"'No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumpe .
All of this estimated
information is non-binding, valid at the time of pumping. Not responsible beyond the date above.
6. System Pur� d By;,1,�
Name Vehicle License Number
L
Company
7. Location where contents were disposed:
Stewart' Regejying Facility, 20 So. Mill St., Bradford, MA 01835
�— See above
S' re Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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