HomeMy WebLinkAboutSeptic Pumping Slip - 35 SHANNON LANE 10/24/2016 - ^
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City/Town of n
System Pumping Record NOV '1 4 2016
Form 41 TOWNC�-NUK[HANDOVER
HEALTH DERAKNIENT
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 310CK8R15.351.
A. Facility Information
Important:When
filling out forms 1. System Lo
on the computer,
use only the tab -
key tn move your xuu,enn
uumor-oonut
use the return rffldovt'�
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key. City/Town State Zip Code
2. System D �
Address(if different from location)
Ci��nwn s�� �� — Zip Code
Telephone Number
B. Pumping Record
I. Date of Pumping 2� C>umnUtV Pumped: Gallons
�
3. Component: El Cesspool(s) r�/�ept|cTonk Fl Tight Tank [l Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? El Yes R No If yes, was |tcleaned? n Yes No
5. 0b d c-yndition of component pumped:
G. System Pumped By:
-Name --- Vehicle License Number
Otewarba Septic 58 So Kimball St Bradford K4
Company
7� Location where contents were disposed:
T 2 11- t bradfordo ma
---
gture of L uler oate
.
Signature m/Receiving Facility� --
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