HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 200 CANDLESTICK ROAD 8/11/2025 Commonwealth of Massachusetts Town 0 f Alorth�n do Ver
City/Town of Lo, Arv\oocr
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System Pumping Record G I rQ
....... ...... Form 4
Heal
DEP has provided this form for use by local Boards of Health. Other forms IT he
information must be substantially the same as that provided here. Before using this!M0rm'%t the
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 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
key. City/Town State Zip- Code
2. System Owner:
fi)cL a e
Name
Address(if different from location)
------------------....................---------
State Zip Code
Telephone----Number
B. Pumping Record
1
1. Date of Pumping Date 2. Quantity Pumped: kallons
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 of qomponent pumped:
--------------------------------
6. System_Jped By:
Name Vehicle License Number
Stewart'sSeptic 1.5.8 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 SoMill St.,Bradford,MA
Signature_of Hauler Date
Signatu4ofkeceivi_n_g_Facility(or attach fa Date------
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