HomeMy WebLinkAboutSeptic Pumping Slip - 1267 OSGOOD STREET 11/16/2017 -
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Pumping
Record K� " ��������� u����o �
DEP has provided this form for use by local Boards of Health. Other forms may be used, butthe
information must be substantially the same as that provided here. Before using this form, check with your
|Qma| Board of Health to determine the form they use. The System Pumping Record must be submitted to
-the local Board ufHealth orother approving authority within 14 days from the pumping date in
accordance with 31OCMR 15.351.
A. Facility Information
'
Important:When '
filling out forms . 1. System Location:
on the computer, -1 nsocy_�d 'A
use only the tab _Vlk;
key to move your A Vq'd )
cursor-do not n
use the return A �'l
key. ""r^"=' State Zip Code
2. 9vtemOmmer:Address(if different from location�_'_
Name
City/Town State Zip Code
'
Telephone Number
B. Pumping Record
1. Date of PunlpinQ2� Quantity Pumped:
DateGallons
3. Component: [] kA B--SepticTankEl Tight Tank F1 Grease Trap
.
El Other(describe):
4. Effluent Tee Filter 0 Yeo [l No If yes, was itcleaned? Yes El No
5. Observed
6. Syste.m-Oumped By:
me Vehicle License Number
ew s Septic 58 So Kimball St Bradford Ma
any
7. ocation w�ere contents were disposed:
so st radford ma
ignatur f Receiving Facility(or attach facility receipt)
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