HomeMy WebLinkAboutSeptic Pumping Slip - 140 MARIAN DRIVE 7/23/2007 Commonwealth of MassachUsetts ®. .
-- —
City/Town of
x
System Pumping Record
Y Fordo
DFP has provided this form for use by local Boards of Health the forms' may,be,Used, bpt the
information must be substantially the same as that provided herd;a. efore usirig�t�i��fi�rrri; check with your
local Board of Health to determine the form they use. The Systern Pumping Record must be submitted to
the local Board of Health or other approving authority.
® Facility Information
Important:
When
farms ainlitg out 1. Sys em Loct!ot�
..._ .-
computer,use
only the tab key ddress
tom y move our dr
cursor-do not
use the return Cityfrown Stake Zip Code
key.
2. System Owner:
VQ Name -- ---- -------�
---------------
r Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping
1. Date of Pumping 2. Quantity Pumped:ate Gallons
3. Type of system: Cesspool(s) ° ' 6ptic Tank ® Tight Tank
El Other(describe): --- -
4. Effluent Tee Filter present? 0 Yes ® No If yes, was it cleaned? ® Yes 0 No
5. on
of System:
6. Syste Pu ed B
------------------------
Name Vehicle License Number
w m
'..
Company
7. Locatio�n__.h�ere ontents ose
n
signat a ark tier Date
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