HomeMy WebLinkAboutSeptic Pumping Slip - 283 CAMPBELL ROAD 11/16/2015 Commonweafth of Ma ac7jnpsetts
No C -
City/Town o f r
System u mping 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 SL;bstantially 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 CUR 15.351.
A. Facility Infollmation
Important:When
filling out forms 1 System
on th computer,
use,one ly the tab
key to move your Address
cursor not
use the return
City/Town State 1�"i 11 ' E
key.
2. System Owner:
Name
return
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record M131!
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes F-1 No
5. Condition of System:
6. System Plum,pd By:
Vehicle
Name -Nurnber, uce
s e, tc Service
7. Location where contents were disposed:
Stewart's Pre-treatrient Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1