HomeMy WebLinkAboutSeptic Pumping Slip - 1935 SALEM STREET 11/16/2015 I
Commonwealth of Massachusetts
- City/Town of A)
System um in 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.
4 P�
A. Facility Information
Important:When
filling out forms 1. S S tl
on the computer, ��W J 1 lU ali � �iII.CIw
use only the tab — - � — - --- 'kL a�
key to move your Address
cursor-do not
use the return _- - —
key.
City/Town State Zip Code
Q2. System Owner: cy
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
I�Z�.,(
1. Date of Pumping ' 2. Quantity Pumped:
Gallons --
Date
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 ❑ No
5. Condition of System:
6. System Pumped By:
Narrre Vehicle License Number
Stewart's Sexlti'c,Service,,..,,-
,
Company,,
7 ",,L6 tio`6 where contents were disposed:
�❑ ��� .,,""'Ste
wart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
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