HomeMy WebLinkAboutSeptic Pumping Slip - 49 CROSSBOW LANE 8/15/2017,
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Commonwealth of Massachusetts
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Stu� Pumping
Record
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Form 4
DEEP "as provided ^^. ' Tor use ^y local Boards OT . .~ . '.. Health. ' Other . ' 10
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 orother approving authority within 14days from the pumping date in
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A. Facility Information
1. ' System Location:
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Address,
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2. System Owner:
Name
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State V
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date ofPumping
Date 2, Quantity Pumped:
/)/~-`/7/7��L��Gal
3. Component: Fl Tank Tight Tank El Grease Trap
L� Other (describe):
4. Effluent Tee Filter present? [I Yes OTINO If yes, was it cleaned? n Yes El No
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5. Observed condition ofcomponent pumped: {
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6. System Pumped By:
StevwartsSeptic 58GnKimball St Bradford Ma
Company
7. Location where contents were disposed:Vehicle License Number
Signature ofReceiving Facility (or attach facility receipt)
Date
t5
form**oo 11/1System 2 Pumping Record `Page 1 of