HomeMy WebLinkAboutSeptic Pumping Slip - 1320 OSGOOD STREET 5/30/2017 - -
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City/Town
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System Pumping Record
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 o[ Health orother approving authority within 14days from the pumping date in
accordance with 31OCPNR15.351.
A. Facility Information
0
Important:When
.~.ng out forms 1. System Location:
-_
on the computer,
use only the tab
key tomove your Address `
cursor'donot
useVmreturn
key. City[Town State ip Code
2. System Owner:
Name
Address(if different from location)
QtyfTo=n State Zip Code
^
Telephone Number
B. Pumping kecord
1. Dabs of Pumping 2. (]uanUh/ Pumped:
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3. Component: [l Cesspool(s) [![ 8epUcTank [7 Tight Tank Fl Gnoaeo Trap
[l Other(describe): ---------
4. Effluent Tee Filter present? Fl Yeo Fl No |fyes, was itcleaned? [l Yen Fl No
5 Observed c dit| of componentpumped:
v", yst Pumped By:
Vehicle License Number
warts S,�optic 58 So Kimball St Bradford Ma
Company
7. LocaAn where contentsW re disposed:
ign lure of Receivin cility(or attach facility receipt) Date
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