HomeMy WebLinkAboutSeptic Pumping Slip - 5 CROSSBOW LANE 5/12/2016 �
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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 uf 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 31OCK4R15351,
A. Facility Information
Important:When
filling out forms /.
on the computer,
use only the tab '
key m move your Add �
cursor do onu1 �—� �
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key. unx/«w» uwm Zip Code
VQ 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date ofPumping 2� Quantity
ua� uon � Gallons
3. Type ofsystem: El Cesspool(s) Septic Tank El Tight Tank [I Grease Trap
[] Other(describe): ----
�
4. Effluent Tee Filter present? El Yes El No If yes, was it cleaned? El Yes El No
5. Condition ofSystem:
8. System Pumped By: �
Name Vehicle License Number
Stewart's Septic-Service
Company
7. Location where contents were disposed:
ShswmrCe Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature ofHauler ���--- Dote /
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record -Page 1 of 1