HomeMy WebLinkAboutSeptic Pumping Slip - 266 LACY STREET 8/15/2017 -
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Commonwealth of Massachusetts
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City/Town��\8/n /���/f uL\ � A n�B�"
System Pumping Record
Form 4 kA
DEP has provided this form for use bylocal Boards ofHealth, Other forms may bmused, but the
information must besubstantially the same as that provided here. Before using this form, check with your
local Board of Health todetermine the form they use. The System Pumping Record must be submitted to
�the |oca| Board ofHealth orother approving authority within 14days from the pumping date in
accordance with 310CIVIR15.351.
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Important:When
filling out forms 1. System Location:
onthe computer,
use only the tab
key tumove your Address
numur-dunot
use the return
key. City/Town State Zip Code
_ _,-_-.. ._.~.:
Name
Address(if different from location)
-6ky—/Town State Zip Code
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Telephone Number
B. Pumping Record |
1. Date ofPump|ng2. Quantity Pumped:
3. Component: � (s) VSeptic Tank El Tight Tank El Grease Trap
El Other(describe): ' �
4. Effluent Tee Filter present? El Yes No If yes, was itcleaned? F] Yes El No
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5. Observed
CA,
6. System
-ka—M Vehicle License
Stewarts tic 58 So Kimball St Bradford Ma
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Company
7. Location where contents were disposed:
20 so mill mtbredfordma
Signature of Hauler Date
'��Tq—natureof Reoe-i-vin 9 Facility(or attach facility receipt) Date
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