HomeMy WebLinkAboutSeptic Pumping Slip - 303 BERRY STREET 10/14/2016 �
Commonwealth �
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System Pump~ng Record NOV ~ zl�
Form 4
TOWN DFN.,`' '<awUOVE�
DEP has provided this form for use by local Boards of Health. {}therformo may beuso buW6. '``'~~''
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:
on the computer,
use only the tab
key m move your Addres
ovmvr do not �)b
use the return � �u Zip Code
key. -,'�—' State
2. System Owner
fh ..................... ..............................
-------
Address(if different from location)
C|tyfTuwn State Zip Code
To|e,honomvmbm,
B. Pumping Record
| 1 Date Pumping �ih/ Pumped:
°�----
/ � o�� `~~~'' � Sa||vmo
3. Component Fl CeaapooKm) 8e[�itTanh El Tight Tank [l Grease Trap
[]
Other(describe): --- -
4. Effluent Tee Filter present? [:1 Yea eNo If yes, was it cleaned? Ej Yen F No
5. Observed cWdition of ponent pumped:
_ -'_
� e Vehicle License Number
Stewarts Se i 588oKimball SVBradford M
Company
7. Location re contents were disposed.-_.----'
'
�ignature u(Receiving Facility(or attach facility receipt) Date
mfonn4.000^11/12 System Pumping Record`Page 1w1