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HomeMy WebLinkAboutSeptic Pumping Slip - 5 CROSSBOW LANE 5/12/2016 � Commonwealth of Massachusetts F���������� �����, � ��� ��' ,�f � � ��|{�7T[����� ��/ �~�*�~� � � � -�~���� ' NOy ��y��tu��� Q�����K�~��K�-��«�����r^� ~ ' ^ �K���� /� TO�NDPNORTHANDOVER M��LTUDEF/]T\|�N� 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 �—� � usathomtum -�—� 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