10 WHITE STREET SYSTEM PUMPING RECORD 8-30-19 - SEPTIC TANK Commomvealth of Massachusetts
City/Town of 5rJem
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 t�e same as that provided here. Before using this form, check with your
local Board of Health to determine the form ti;ev 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, 10
use only the tab
key to move your Address
cursor-do not J me-rA
use the return MA
key. City/Town State Zip Code
40--N 2. System Owner:
14,4
Name
eaen
Address(if different from iocation)
Cityrrown State -7 4 Zip Code
q -7 Cl T CIO
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 4---"'Septic Tank El Tight Tank F-1 Grease Trap
F Other(describe):
4. Effluent Tep. Filter present? E] Yes Z"No If yes, was it cleaned? Ej Yes F No
5. Observed condition of component pumped:
GOO e-
6. System Pumped By:
W 7 r?"
Name Vehicle License Number
Wind River Environmental Haverhill WWTP
Company
7. Location where contents were disposed: 40 S Porter St
Bradford, a 01835
Signature of Hauler Date
Signature of Receiving Facility(or attach faciKy receipt) Date
t5form4.doc-11112 System Pumping Record-Page 1 of 1