HomeMy WebLinkAboutSeptic Pumping Slip - 705 MIDDLETON STREET 12/8/2016 ' |
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Commonwealth of Massachusetts
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City/Town ^//
System Pumping Record
' Form 4
DEP has provided this form for use by local Boards of Health, Other forms may be msed, 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 31OCIVIR1B.351.
A. Facility Information RECEIVED
Important:««hen
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Location-
on the computer,
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key. Qt�fruwn State Zip Code
2. System Owner: �
Name
QtyJown State Zip Code
.
Telephone,Number
B. Pumping Record
1. Date of Purnping 2� Quantity Pumped:
Date 3. Component: El Cesspool(s) Septic Tank El Tight Tank F-1 Grease Trap
M Other(describe):
No 4. Effluent Tee Filter present? If yes, was it cleaned? F] Yes El No
5. Observed condition of component purnped:
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Name Vehicle License Number
Stewarts;Septic 58,'�o Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill stbredfond ma
Signature ofHauler Date
nature of Receiving Facility(or attach facility receipt) Date
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