HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 5/12/2016 �� `
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K� uK��^ng Record �O���
DEP has provided 'this lonn for use by local Boards ofHeabh Other forms maybe used . �m
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thelocal Board ofHea�horot er approving autho-- ^�in�~~'" ' ""p" �cvoee«on �
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A. . ~^~="�y o x u o oo u x xc«uxon
Important:When
xmngmut forms 1 System Location:
on'
k_, o move your ^ooreuo -'----- ----- '------_ - _____-_---'
cursm-uon�
use the oetvm North
key. City/Town �--------- --'--' �
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System '` � ���
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Name / - ---'- -- --------__-_--__-_- |
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*uun�o(no*��n hom )------- - -' -- --'-'----------
oityn own .'__ -Zip Code State
Telephone Number
B. PUMPing Record
1. Date ofPumping -(�" 2. Quantity Pumped,
Date Gallons
3� Type ofsystem: Fl Cesspool(s) SepticTenk E7 Ti htTank Grease Tr |
F7Other¢�esorbe>� ------'_-'--_,'�------------- -'--------------
4. Effluent Tee Filter present? �� Yes F� No h
�� �� yea, was it cleaned? El Yes 17 No
h. Condition of8yo&*m�
___---_-'---_'__-________-_ !
h. Symtem Pumped By�
mame �------------------- _'__'__-' -- ----'-
vehiu�eLicenonmu�ue, ---------'
Stevvart's Se pti c Se ry i ce
Company
/ Location where contents were disposed:
Stevvart's Pre-treatment Plant, 20 So Mill Bradford, Ma 01835
olynanvre,»Hauler --'�---'-'---' ------_'''-' . ----
Date --------
sgna�=m�Wt;xi�����- ' - -- - ' �' -- ------
~ — Date ---------- �
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System Pumping Record Page