HomeMy WebLinkAboutSeptic Pumping Slip - 1077 OSGOOD STREET 5/7/2018 ���������
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HE&3HOORARTME'if
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other forms may be used, but the
information must be euhutanUe||y the same as that provided hens. Before using this forno, check with your
|oom| Bnmn1 of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health orother approving authority within 14 days from the pumping data in
accordance with 31OCMR 15.851.
A. Facility ''--_-'-'_~'-~''
Important:When
filling out forms 1. System Location:
onthe oomputer, ( i
use only tab / v
�y�mve Addressyour *uunn - -
oumnr'do not
MA
use the return
key. City/Town State Zip Code
2� 8ystemOwn
Name
Address(if different from location)
CKy/Town State Zip Code
-
Telephone Number �
B. Pumping Record
1. Date of Pumping oata 2. Quantity Pumped: Golions —
3. Component Fl Cesspool(s) [l Septic Tank Fl Tight Tank [V~dn*aneTrap
�]
Other(describe):
4. Effluent Tee Filter present? [l Yee E7 No |fyes, was itcleaned? 0 Yes [l No
5. Observed condition nfcomponent pumped:
................. .......
-
— _'-'_m Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball Sdfo A
Company -
7. Location where contents were disposed:
20 So. K8i|| St. Bradford, MA
~
Signature ofHauler Date
Signature ofReceiving Facility(or attach facility receipt) Date
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