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HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 98 MARIAN DRIVE 5/29/2024 Commonwealth of Massachusetts I City/Town of � System Plumping Record FED 025 Farm 4 2 DEP has provided this farm for use by local Boards of Health. Ot A ed, but the information must be substantially the same as that provided here. Before usin tck 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, _._..........._.......... ..w__._...._.............._ __...._...__.,_ _..__.._.__.._..._.__.___.._____...__..... __....__...__ ._w_._.._._._._._._..._.._. A. Facility Information Important:when filling out forms 1. System Location: on the computer, { ,„, use only the tab 4,.. _ key to move your Address cursor-do not use the return " _. _.. _ ..._....___._._ key. ity/Town State Zip Code 2. System Owner: _ Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record _ 1. Date of Pumping 2, (quantity Pumped: Date Gallons 3. Component: C] Cesspool(s) e septic Tank ❑ Tight Tank Grease Trap ❑ Other(describe); 4. Effluent Tee Filter present? Yes ❑ No If yes,was it cleaned? R Yes F� No 5. Observed condition of component pumped: yM m Pumped By:�. System C Name Ve 11 hicle License 11 Numbe 11 r Company "T. Location JH"a where contents were disposed: Signat Date __Signat act i (or attach facility receipt) Date t5forrn4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts Town of lVorth MdOver City/Town of 05 rc system Pumping Record Health Farm 4 LIEF' has provided this form for use by local Boards of Health. Other farms 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 15.31. A. Facility Information Important:when filling out forms 1. System Location: on the computer, ee� use only the tab s _. I _ 4 key to move your Address cursor-do not i use the return ' key. C�ty(Town State Zip Code 2. System Owner: Name _ Address(if different from location) _.. ._ _._ _...._........_........ ......... . _ .... .... City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Component: [-1 Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? n Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condtion of component pumped: 6. System Pumped By: .. �` . Name yr f a Vehicle License Number 6 Company 7. Location contents were disposed: _ ---------- _..__ ----..__...- ...... .... Sign ur f Mauler _. Date - __ _.. _...__ .._._. _ _......._.m ......... -----..__.. Signature o ing Facility(or attach facility receipt) Date t5form4.doc-11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts Town City/Town of System Pumping Record 4 2025 Form 4 . earth DEP has provided this form for use by local Boards of Health.Other forms m th information must be substantially the same as that provided here. Before using this for with your local Board of Health to determine the farm 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 farms 1. System Location: on the computer, use only the tab _ .. _....... ,. .. key to move your Address cursor-do not use the return ----. __ key. CitylTown State Zip Code 2. Sy tem Owner: t -- Name Address(if different from location) City/Town State C _jp Code w Telephone Number B. Pumping Record 1. Date of Pumping De 2. Quantity Pumped: Gallons . Component: ® Cesspool( ) Septic Tank ❑ Tight Tank Grease Trap ❑ Other(describe). 4. Effluent Tee Filter present? ® Yes No If yes, was it cleaned? [ Yes No 5. Observed con `tion of component pumped: s Pumped By:6. � � Name Vehicle License Number Company 7. t ocation wh ontents were disposed: Signattife of uler Date Signature of l2ec lity(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record Page 1 of 1 Commonwealth of Mass achusetts 4/7 Ofn aVer w City/Town of -VA ma'Ode4 System Pumping Record 025 Form 4 Health DEP has provided this form for use by local Boards of Health. Other forms m a but the information must be substantially the same as that provided here. Before using this o eck 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 CfVIR 15.351. A. Facility Information Important:When filling out farms 1. System Location: on the computer, use only the tab ..... _ key to move your Address cursor-do not 9�t use the return "..N _ ._............. .. ..._ _ _.._. .. ... key. City/Town State Zip Code 2. System Owner: - . -- Name Address(if different from location) City/Town state Zip Code Telephone Number B. Pumping Record 1. Date of Pumping _ .......� 2. Quantity Pumped: � Date Gallons 3. Component: [-1 Cesspool(s) Septic Tank ® Tight Tank Q Grease Trap ❑ Other(describe): _ _ _....... .. ...... 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? [l Yes (l No 5. Observed con "tion of component pumped: System Pump BY w (TM �`° 5. ys � � Vie.. Name Vehicte License Number Company 7. Lto'", ntents were disposed: s Datag F y(or attach facility receipt) Date t5form4.doc!11/12 system Pumping Record•Page 1 of 1 To Wn Of Jvotth Commonwealth of Massachusetts aver City/Town of t Syst em Pumping Recorc! µix p '� °.; Form 4 DEP has provided this farm for use by local Boards of Health. Other forms may be u 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 fining out forms 1, System Location: on the computer, ( r use only the tab .. _1 h key to move your Address cursor-do not use the return key. City/Town State Zip Code 2. System Owner: r n Name 11 Address(if different from location) Cityil own State Zip Code Telephone Number B. Pumping Record 1, Date of Pumping ............ 2. Quantity Pumped: Crate Gallons 3. Component: ❑ Cesspool(s) eptic Tank E] Tight Tank ❑ Grease Trap E] Other(describe): 4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned"? F ] Yes ❑ No 5. Observed con ition of component pumped: _ ..... , . _............_ _--- 6i System Pumped By: � LOCO, � , X... __ ._... ___ _._.._ _ _ ------- -_-. Name „ yypyp pg Vehicle License Number Company 7. Location wh contents were disposed: Sig ur o Hauler"" Crate Signatu calving Fa '' (or attach facility receipt) Crate t5form4.doc•11/12 System Pumping Record•Page 1 of 1 417 of lVor Commonwealth of Massachusetts V City/Town of lz r System Pumping Record _. Farm 4 DEP has provided this farm for use by local wards of Health. Other farms may be usec9!041he 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 Informationy Important:when filling out forms 1 S stem Location on the computer, use only the tab _. ----- _ '_. _ ' key to move your Address cursor-do not r --- - -- - use the return --._ _......._._.____.__.__...-__---� _.. ........_._____--_ -_- key. City/Town State Zip Code 2. System Owner: e k d\,p .w Name roar Address(if different from location) ...... ...... _....- City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) Ekieptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Na If yes, was it cleaned? ❑ Yes ❑ No 5 Observed con tion of component pumped: 676 6. System Pumped By: Name Vehicle License Number Company 7. Location wherq contents were disposed: r . e ...... ....._.._._._ _. ...................._. ..._.. _ .._... .__............._.. _ _......_... -....... ........_._..... Si ure Hauler Date Signatur of e ' dng Facility attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts 617doVer 4 City/Town of45 System Pumping Record Form 4 ek�s ° q DEP has provided this farm for use by local Boards of Health. Other farms may be use Raft 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. S Stem Location: on the computer, use only the tab __.... . ....__... key to move your XF s cursor-do not use the return __ _. .... ---___--- --- _-- _ .__.......... _........ ._.. -- key. City/Town State Zip Code 2. S ste n, Owner: rah Name . Address(if different from location) _ _. ................ .._. .--.... .. ----- ---._--- _ -- City/Town State Zip Code - .._....-............-----------..__..__..- .._..._--_---- Telephone Number B. Pumping Record 1. Date of Pumping -date ..._ ...... ......__..__... - 2. Quantity Pumped: _.._._.. .. Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): _...... ___... -- ..... 4. Effluent Tee Filter present? ❑ Yes IVa If yes,was it cleaned? ❑ Yes ❑ No 5. Observed conditi n of component pumped: r� 6. System Pumped By: --_ rc ----- --------. __ _ _ .... - f ....... Name Vehicle Icense __._...... Number Company 7. Location wh a antents were disposed: ............ _.. -.... - --- --_.._ ---------------- ------ - - Sigrfafure of auler Date _.. _. _ _._.... ----- _.... _. -_--. -.._.. Signature o wing Facility(or ch facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 _ Commonwealth of Massachusetts ��- City/Town of .. System Pumping Record Zp Farm 4 eel CEP has provided this form for use by local Boards of Health. other forms may be u information must be substantially the same as that provided here. Before using this form, WhUth 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 3_Q._... "7 ._._.__ _..__._. _--------- key move cursor do noour Address __.__._.�_. usethe return — ........... -- ._..._..... ...._......- — .__...... .... _ ......__._..._._...._... ---........_..._.............. - ------........_.._......-----� key. City/Town State Zip Code VQ 2. SystemOwner: Name 11 Address(if different from location) City6Town State Zip Code Telephone Number B. Pumping Record 1. Cate of Pumping Da--t_te Ga_____ _ 2. Quantity Pumped: ----__ _. .. _. llons 3. Component: ❑ Cesspool(s) Septic Tank © Tight Tank Grease Trap ❑ other(describe): ....... 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. observed coedit' n of component pumped: .. .. 6 System Pumped By --le'rely14 ........... ..................................... Name _ .w. ._ e a _ 47 /"�� jJ0 �,� � � hide License Number .. l Company 7. Location where contents were disposed: _ ... ........ _. .._..._. . .._..._.._...._.. _..... _.._- _. .....__ _ .._.. ..._.___Si� ture �'PtauLier Date Signature of Re- g adlity(or attach facility receipt) Date t5form4.doc-11112 System Pumping Record-Page 1 of 1 Town Of Commonwealth of Massachusetts leer City/Town of System Pumping Record ow u Form 4 el , DEP has provided this form for use by local Boards of Health. Other forms may be use 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 _ __ key to move your Address cursor-do not " use the return — �- ---.' __..._ _ -- ----- key. City/Town State Zip Code 2. System Owner: Name i Address(if different from location) -__ _ ..._..__... ___ ...... ._.....__._ _.._----,. _ _..._.._ .__._.__ _ City/Town State Zip Code Telephone Number B. Pumping Record 1, Date of Pumping 2. Quantity Pumped: - � — Date Gallons 3. Component: ® Cesspool(s) Septic Tank ® Tight Tank n Grease Trap ® Other(describe): 4. Effluent Tee Filter present?,eyes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: cx 6. stem Pumped By: Name Vehicle license plumber Company 7. Location where contents were disposed: Sig ture f u Date Signature of Ivjng Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 of Commonwealth of Massachusetts c �� _ r City/Town of " °ter " FE9 - System Pumping Record 2025 Farm 4 llealtho DEP has provided this form for use by local Boards of Health. Other forms may be used, information must be substantially the same as that provided here. Before using this form, checc ith 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 . .. --- _..._... key to move your Address cursor-do not use the return key. `City/Town State Zip Code 2. System Owner: Name Address(if different from location) _..................... . .........__.. _--- ---------------- _------ ... ._._-.---- - _.. City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Daq - .-------''._....______...._.._...._._ 2. Quantity Pumped: Gallons_...__ -...- 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe); _.-__ _. _ _ ______.. _. 4. Effluent Tee Filter present? ❑ Ye No If yes,was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: - - y Pumped By:6. System ...._.... --------------- _._._ _......_..__....._-_ Name Vehicle License Number Compan 7. Location where contents were disposed: _— .... _..------------ - Sig r of er Date ....... Signat eiving cility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 rotv rr lvoltb Commonwealth of Massachusetts City/Town of uSystem Pumping Record llecwth Farm 4 " 41C DEP has provided this form for use by local Boards of Health. Other forms may be used, but thee 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 farms 1. System Location: on the computer, L, use only the tab ..w . . ...... ... ....... _.. ._-_ key to move your Address cursor-do not NP of use the return __ _ _ _ ._.__ ._....... _., _. . -.._ Sta e Zip Cade key. City/Town 2. System Owner: � — Name as Address(if different from location) CitylTawn Mate Zip Code Telephone Number B. bumping RecordWAD . e I. Date of Pumping G 2. Quantity Pumped: _allo.,.. Date ns 3. Component: ❑ Cesspool(s) ®Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): _ 4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed con 'tion of component pumped: 6. System Pumped By: 6 _- _._-- - -_ . _ Name Vehicle License Number ! .- ompany 7. Location here c ntents were disposed: �. Signature of r Date __ ...,...,.... _......_..... Signature of e eivi Facility(or a ch facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massac husetts r1 City/Town of System Pumping record sw Form 4 � DEP has provided this form for use by local Boards of Health. Other forms may be t the information must be substantially the same as that provided here. Before using this form, th your local Board of Health to determine the form they use.The System Pumping Record must be su fitted 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 _ � w.. .---._.__✓.. __w___ ___.. Important:When filling out forms 1, System Location: on the computer, use only the tab - _ . . ._.. ___. .... ---------- _.. _ - ...... key to move your Address cursor-do not AndOLRf use the return ---..__ ___.._ ........ _..... ._ ..-._.. _ --._. key. City[Town State Zip Code s 2. System Owner: , ....._ Name r Address(if different from location) _........_ _ . ........... _ _.......-. ------ ....... .. _ _. _ _... City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Gate Gallons 3. Component: ❑ Cesspool(s) Eglleptic Tank ❑ Tight Tank ❑ Grease Trap ❑ tither(describe): 4. Effluent Tee Filter present? ® Yes No If yes, was it cleaned? ❑ Yes ® No 5. Observed con ion of component pumped. 6. System Pumped By: Ngme Vehicle License Number Company 7. Location wh e contents were disposed- Si ore Hauler Date Signatu of ing Facility(or ttach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Wage 1 of 1 10W/7 of h Commonwealth of Mass chusettsv �" City/Town of � - r System Pumping Record r � . Farm 4 E? DEP has provided this form for use by local Boards of Health. Other farms may be used, jt 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 computer, y 1. System Location: tion: o use only the tab _ key to move your Address cursor-do not 7 use the return _ ._ _.. key. City/Town State Zip Code stem Owner: VQ .. _ .._. ........... - Name Address Of different from location) City/Town State Zip Code Telephone Number _ _ B. Pumping Record 1. hate of Pumping p 11 ate allons 2. Quantity Pumped: _ ....... . __ ..._..... G 3. Component: ❑ Cesspool(s) MSeptic Tank ❑ Tight Tank ❑ Grease Trap n Other(describe): 4. Effluent Tee Filter present? ❑ Ye�No If yes, was it cleaned' ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: co (TO .f M .._....... .........__ N me ehicle License Number Company 7. Location where ntents were disposed: ......-._ __.. �.... Sin� r�of ...,��,gu _, � ._ _...__ m.... ___ ....__.__ Date g au r .... _ ........ -.---------- _.. ... �............ Signature of eivi acility(or at ch facility receipt) Date t5form4.doc•11112 System Pumping Record*Page 1 of 1 A,V. h,4 Commonwealth of Massachusetts over City/Town of N o w System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, bu 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 key to move your Address cursor-do not r use the return ____ key. City/Town State Zip eode 2. System Owner. .. ____.._. .__.____ . . _..__ _..---. . ._._ ---_ __Name ._.. __ ---- ._ Address(if different from location) -- - _ .._ _-._--- ........._. -- _ . City/Town State Zip Code _— _._..................__._.---- --._-_____._ Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): --.._.. _ __. 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Observed condition ndi tion of component pumped: 6. System Pumped By: __..._ _---------------- Name Vehicle License Number al Company 7. Location here contents were disposed: Si atur of Haule� Date _ a' ._..- _ ..._._.__ __._ -..._ __._... ------ Signature f Receiving Faciii (or attach facility receipt) Date t5form4.doc-11/12 System Pumping Record-Page 1 of 1 Commonwealth of Massach efts City/`Town of �x pV System Pumping Record �� jqt Farm 4 w. a DEP has provided this form for use by local Boards of Health. Oth I be used, but the information must be substantially the same as that provided here. Before i form, check with your local Board of Health to determine the form they use, The System Pumping Rec e submitted to the local Board of Health or other approving authority within 14 days from the pumpingloot accordance with 310 CMR 15.351 A. Facility Information Important:When filling out farms 1. System Location: on the computer, use only the tab key to move your Address cursor-do not 1 use the return _. key, C4/Town State Zip Code 2. System Owner: VQ Name Address(if different from location) . .......__..._ Cityffown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping D-a te 1 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): _ 4. Effluent Tee Filter present? M Yes,,"No If yes,was it cleaned? ❑ Yes F-1 No ,. Observed con ition of component pumped. 6 System Pumped By .me Vehicle License Number Company 7, Location . wh re contents were disposed. .............. 69"', ature Hauler ` Date Signature ing Faci!!y,(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts f City/Town of L �� System Pumping record W. Form 4 w, 42025 ' ec, LIEF has provided this farm for use by local Boards of Health. tither forA% used, but the information must be substantially the same as that provided here. Before using check with your local Board of Health to determine the form they use.The System Pumping Record mu pbmitted 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, r use only the tab ..� .... .. ":. key to move your Address cursor-do not _ '.. .._. . ...w,. ..._....._, _ _ ._.__ e use the return _ key. Ci y own State Zip Code 2. System Owner: W Flame Address(if different from location) _.._.... .. .. .... City/Town _ ... State Zip Cade Telephone Plumber B. Pumping Record 1, Date of Pumping 2:. Quantity Pumped: _. _......... Date Gallons 3. Component: [ ] Cesspool(s) Septic Tank ® Tight Tank ❑ Grease Trap ❑ Other(describe): _ _ ... 4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? Q Yes R No 5. Observed con ition of component pumped: 6. System P roped y: �. Flame y/` Vehicle t„ioe Plumber Company 7. Loc tion w er contents were disposed: Sig 11.1 rrature o auler Date Signature f R ing facility_(prdftach facility receipt) Date t5fdrm4.doc•11/12 System Pumping Record•Page 1 of 1 <C\ Commonwealth of Massachusetts City/Town of No Andover 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 Recoid must be'submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CIVIR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Name Address(if different from location) No Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallo As 3. Component: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap F-1 Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes F-1 No 5. Observed condition of component pumped: &0 eq A 6. Syst@ u4nnqd By: Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 SoMill St.,Bradford,MA Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc-11/12 System Pumping Record-Page 1 of 1