HomeMy WebLinkAboutSeptic Pumping Slip - 56 SUGARCANE LANE 5/12/2016 Commonwealth � ef�
City/Town of A Vi o V e,-Y'
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—� -- Pumping�� ^ ^ ^ ~~ DFNORTHAMDOVER
Form 4 }uV m LTHDEp,KT�ENT
OEP has provided this form for use by local Boards nfHealth. Other forms may be used, but the
information must be substantially the same os that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to �
the local Board of Health nr other approving authority within 14 days from the pumping date in �
accordance with 31OCK8R15.351.
A. Facility Information
Important:When
filling out forms 1. System Location,
on the computer,
use only the tab �
key k,move your Ad - -- ~~
numv, do not
use the return _Ana( ---- --
key. C/'n/»w» xmm Zip Code
2. System Owner:
Name C -=—��-----
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C/ux/nwn State Zip Code
Telephone Number
B. Pumping Record /I /'
1. Date of Pump 2. Quantity Pumped:
ing Yate _1 Gallons
3. Type of system: Cesspool(s) FI/Septic Tank n 'Fight Tank El Grease Trap
Fl Other(describe):
4. Effluent Tee Filter present? [l Yes Fj No |f yes, was itcleaned? Fj Yes [l No �
5 Condition cfSystem: \
6. System Pumped By:
.~.-
7. Location where contents were disposed:
Stewad's Pre-treatment Plant, 20 So K8iU Bradford, (Na 01835
Signature of Hauler Date
|
Signature ofReceiving Fmj|hy Date
t5fonn4dmc-03108 System Pumping Record^Puge 1 of