HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 506 BOSTON STREET 9/6/2024 Commonwealth of Massachusetts
City/Town of .My.
o 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, O
use onlylythethe tab 1V
key to move your Addres
cursor-do not 'W, �,e MA
use the return key. City/Town State Zip Code
2. System Owner:
-Saflicrt� _ Lot�-o Kv L '0 O
Name
seam
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: iGa�hlonsx~
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 1� No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
9 0C}CA 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:
ZNU s
Name Vehicle License Number
Company
7. Location where contents were disposed:
StewA���
aart'sReceiving Facility, 20 So. Mill St., Bradford, MA 01835
�:— \e-< 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