HomeMy WebLinkAboutSeptic Pumping Slip - 11 CHERISE CIRCLE 10/12/2016 Commonwealth �
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System Pumping Record
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DEP has provided this form for use bylocal Boards of Health. Other forms maybe
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information must be substantially the same as 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 or other approving authority within 14 days from the pumping date in
accordance with 310 CK4R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
un the computer,
uae only the tab
key m move your xuuemo
cursor'uunot
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key. City/Town state Zip Code
2. System Owner:
___-____ _._l__-__
mumm
Address(if different from location)
City/Town State Zip Code
Telephone Number
-------'
B. Pumping Record
1. Date of Pumping mm* 2� <�uard�y Pumped:
3. Component: [l Cmompoo|(n) �P Septic Tank [l Tight Tank El Grease Trap
E] Other(describe): -------- -----
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? [l Yes [pP No
5. Observed condition of component pumped:
� �____ _-_'_-'__-
i
0. System Pumped By:
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mmve Vehicle License Number
8tewa ts Septic 58 So Kimball St Bradford Ma
Company
7. Location wh
20 so mill ord a
Signatu of Hau Date
Signature of Receiving acility(or-attach facility receipt) Date
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