HomeMy WebLinkAboutSeptic Pumping Slip - 1469 SALEM STREET 1/22/2018 . "
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System Pumping Record
Form |
DEP has provided this form for use bv �ua| Boards ofHealth, Other forms may baused, but the
information must beswb�endai|ythe
�same as that |d here. Before using this form,check with yop/
|noa| Board ofHealth hodetermine the form they use` .ha�yohsm -
P mp|n ReooRecordmus�beoubm/ned to
the local Board of Health or other approving authority within 14days from epumpingdate in
accordance with 31DCMR 16.261
A, Facility Information � ---'
Important:Whev
filling out forms 1 SyehamLooahon'
*vthe computer
use only the tab14 _[~_ - ---------
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use the rewm ________
key ~�'v~" State Zip Code
2System Owner
Name - -- ' -'---------------- ''-------- ----- --- '
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Tk�7fow' n -' � - ' -' -'^------- StateZip---'- _--Code____ _
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B. Pumping Record--- Telephone Number
1 Date of Pumping Quantity Pumped:
Cate
3� Component C1 Oeoopom|(e) 2�`SupdcTanK n T|ghtTank Grease Trap
Fl Other(demcr'be)�
4 Effluent Tee Filter present? 0 Yes U^N10 If yes, was It cleaned? 0 Yeo Fl No
5� Observed condition ofcomponent pumped'
6. Syste.,rQ Purnpq'Iii By
wa�;e ' --------'- -'-----' -- '-------- '
Vehicle License Number
Wind River Environmental
Company �---------------~'------
7 Location where contents were disposed:
w"e of Hauler - ��-------- ----- '-------- ' '--
emoam�n/Rw�mivmwpm�o,v�� c 17l�� - ----------� - - ------- ��
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� AMtam Pumping Record^Pame / Q, ,