HomeMy WebLinkAboutSeptic Pumping Slip - 101 CHRISTIAN WAY 12/19/2017 ' |f�' ' ' 1 � ?0�
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System Pumping Record »����DILI
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DEP has provided this form for use bylocal Boards ofHealth, 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 submitte-i to
the local Board of Health or otherapproving authority within^ 14 days from °the pumping date"'
accordance with 31OCk«R15.351
A. Facility Information
/ When
filling out forms 1 System Location,
oothe computer,
use only the tab
key wmove your Address --- '---------' -------'---'- --
cursor'uvnot
use the return -----'- - ----- q9-
key °''r'"~°
^ State Zip com'- ' ---
2. System Owner
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Name ' - ----------'----- ''-------- ----- ' --- -
*ouren (ilul�eren frnm|o9axum) �----- ' ' -----------' - ------- '--- ''
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Zip Code
Telephone Number '------ --
B. Pumping Record
3 Component: E] Cesspool(o) Septic Tank [] Tight Tank Fl Grease Trap
LJ Other(describe).
4 Effluent Tee Filter pneoentr Fl Yes 9 No If yes, was |tcleaned? Yea No
5� Observed condition ofcomponent pumped:
5. System Pumped By.
Name
Vehicle License Number
Wind River Environmental jJaV("j
Company ;rf)jjj
7 Location where contents were disposed:
`
47R) 24 F-4.—�)7
i�i3nlure n'Hauler — Date
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=ynoweof�po wmm+wooty¢xatmc^umave"oipV��- lDate ' ----'----- ' ------ '
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System Pumping Record'Page ' a'