HomeMy WebLinkAboutSeptic Pumping Slip - 227 GRANVILLE LANE 7/5/2016 �������
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City/Town of
System Pumping Record
B*
uFAL3�DEP��T�EN1
Form 4 ^—
DEP has provided this form for use by local Boards of Health. Other forms may be used, butthe
information must besubstantially the same as that provided here. Before using this fomn, 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 or other approving authority within 14 days from the pumping dote in
accordance with 31OCN1R15.851.
A. Facility Information
Important:When
filling out funno 1. System Location:
m computer,
use GRAN\0LLE LANE
key to move your Address
cursor'munot NORTHANDOVER MA 01845
use the return
City/Town State Zip Code
key.
2. System Owner:
~—A JAKE CHACE
Name
-------
Address(if different from location)
C|hvTowo State Zip Code
Telephone Number
B. Pumping Record
7/D/ 8 1
1 Date ' 2 Quantity Pumped: --
� oom � � Gallons
3. Component: Fl Ceompoo|(s) 0 Septic Tank El Tight Tank Fl Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? 0 Yes El No If yes, was it cleaned? 0 Yes El No
5. Observed condition of component pumped:
GOOD CONDITION
O. System Pumped By:
JAMES H CURRIER 11 M/84
Name Vehicle License Number
J' 6EPT|C& DRAIN
Company
�
7. Location where contents were disposed:
GLGO
7/5/16
S—ignatt -of Hauler Date
Signature"f Receiving Facility(or attach facility receipt) Dote
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