HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1288 SALEM STREET 12/15/2025 I Commonwealth of MassachusettsT ownc)flVo Wer
:W City/Town ofJa.
w° System Pumping RecordAo
r Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be u e , O)t
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 _ -- —._.._. _-.__ .._. .?..... "'---c _ .__._�
key to move your Address
cursor-do not
use the return - ___
key. City/Town State Zip Code
2. System Owner:
Na
—.m....e........ --
- _.... -- ..._...... ___—.
Same
_ _- --
A dress(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - 2. Quantity Pumped:
Gallons
3. Component: Cesspool(s) Y Septic Tank Tight Tank [ � Grease Trap
� ] Other(describe): --...._. - -_-
4. Effluent Tee Filter present? Yes _J No If yes, was it cleaned? [ es I No
5. Observed condition of component pumped:
__..-..._ ....._... .._..... ....- . .._
6. Sys -
Pumped By:
_..._._ ----..._ ........
Name Vehicle License Number
Stewart's Septic 58 So Kimball St_ Bradford,MA
—......- ---- ..
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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