HomeMy WebLinkAboutSeptic Pumping Slip - 145 FARNUM STREET 8/15/2017 ~
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wealth of Massachusetts
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S�ystern Pumping u��pUn�� Rec��m �
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DEP has provided this form for use bvlocal Boards ofHealth. Other forms may boused, but the
information must bmsubstantially the same amthat provided hana. 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 31OCK4F( 15.3O1.
A. Facility Information
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Important:When '
filling outfomns . 1System Location:
vnthe computer,
use only the tab
key mmove your /ddnueo �~
vommr-duno* _
use the return
key. °''''"w'' State Zip Code
2. Slystenn Owner:
Address(if different from location)
City/Town State Zip Code
Telephnne Number
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B. �
=. Pumping Record
1. Date of Punn 'ng2. Quantity Pumped:
Date�l Component �l Cesspool(s) Tank Fl Tight Tank Fl Grease Trap
.
Fl Other(describe): '
4, Effluent Tee Filter present? El Yes 0-No If yes, was itcleaned? 0Yes E] No
5. Observed condition ofcomponent pumped:
6. System Pumped By:
N'ame Vehicle License Number
Stewarts Sti 58 So Kimball SBradford
Company
7. Location where contents were disposed:
20 so mill
Signature of Receiving Facility(or attach facility receipt) Date
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