HomeMy WebLinkAboutSeptic Pumping Slip - 89 CHRISTIAN WAY 12/8/2016 ~ -
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System Pumping Record
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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 Syotem ntbe submitted to
the local Board of Health or other approving authority v�thin 14dayaf 4 datmin
accordance with 310CK4R15351
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A~ Facility Information TDMNDF NUR THANDOVER
HEAL HDEP����ENT
Important:When -^
filling out forms 1. System Location:
on the computer,
use only the tab
key m move your xduream
cursor do not
use the return -------- -----------------
key. City/Town State Zip Code
2. System Owner: + �
Address(if different from location)
--- �
cityfT �� Zip Code
e
Telephone N6mber
B. Pumping Recoird
1. Date ofPumping mom 2. Quantity Pumped: Gallons
3. Component: ,4/Fl Ceoopuo|/o\ L�'Septic Tank Fl Tight Tank [l Grease Trap
El Other(describe)-
4. Effluent Tee Filter present? El Yea El No U yes, was itcleaned? El Yes U No
5. Observed condition of component pumped:
6. S —
Name Vehicle License Number
-----
|
Company
! /. Location where contents were disposed:
20aomill atbradford ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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