HomeMy WebLinkAboutSeptic Pumping Slip - 700 CHICKERING ROAD 1/22/2018 v 13PP has provided this form for use by local Boards of Health. Other forms may be used,but the
information must be substantially the some 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 submitted tb
the local Board of Health or other approving authority within 14 da s front t ru , ate in
accordance with 310 OMR 15.351,
A. Facility information
Impo
When filling
1 System Locatia
vuh+�r t911tng Out TOWN NOKTH AN00VER 1,
forms an the -4
computer,use �» _. _
only the lab keys Address ,�yw, /� '"
to move your �,, til" !' 1 �/� r
GulSor-do not lvltyCl'prMn Zi- • State .. P Code
use the return
Bey' 2. Sys errs owner:
Name
Addfo$s(if different from location)
cityrrown._ State Zip Cade
Tate-phone Number
B. Pumping Record _
1 I lo_" _1 ._.._ 1Dpl:?.�.
1, bate of Pumping nate 2. Quantity Pumped: Gallons m
C t-eA'U-4"
3. Type of system: ❑ Cesspool(s) SepW Tank Q Tight Tank Q Grease Trap
fD Other(describe):
4. Effluent Tee Filter present? C] Yes jo No if yes, was it cleaned? Q Yes v
5. Condition of System:
fi. System Pumped Bye
Name � r Vehicle License Number
W t! 1 i1a _ iI4 y'i rq_h r `�E:r•. Qol
Company
7. Location where contents were disposed
_ Eadh_ ource Inc.
signature of Hauler 1950 Broadway
Date
Signature of Recet �f l l"IG�Ii� �•� � �� date
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