HomeMy WebLinkAboutSeptic Pumping Slip - 47 WILLOW RIDGE ROAD 10/17/2016 - ^
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System Pumping Record
Hf�L HDEPAAT�EN�
Form 4 -
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 31OCyNR15,351,
Important:When '
filling out forms 1. System Location: '
vn the computer,
use only the tab
key to move your vuureom ^/
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return -----, — ---- --------------
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Z System 0vv
Name
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Cayrrown � State - Zip Code
B. Pumping Record
1. Duby of Pumping Date /--�/��-- 2. Quantity Pumped: Gallons
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3. Component: [] Cesspool(s) �� SepdoTank El Tight Tank Fl Grease Trap
L] Other(describe):
4. Effluent Tee Filter present? U Yes F1 No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
8. System Pumped By:
Name Vehicle License Number
Stewarbs Septic 58 So Kimball St Bradford K8
Company
7 Location where contents were disposed-
so
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Si nature m Haute~ ~— Date
Signature of Receiving Facility(or attach facility receipt) Date
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