HomeMy WebLinkAboutSeptic Pumping Slip - 20 CHRISTIAN WAY 12/8/2015 Commonwealth of Mas Ch tt
City/Town o f
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 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
cursor-do not ❑
use the return Cikylfown State Zip Code
key.
Q2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date V5- 2. Quantity Pumped: Gallons
3, Type of system: ❑ Cesspool(s) tSeptic Tank ❑ Tight Tank F-1 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes F-1 No If yes, was it cleaned? F-1 Yes ❑ No
5. Condition of System: q
6. System Pumped By:
Name
Vehicle License Number
Cs:
SZ
lc�
Stemtrt's S tic;
Compan7—
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
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