HomeMy WebLinkAboutSeptic Pumping Slip - 68 LACONIA CIRCLE 8/2/2018 Commonwealth of MassachUcAmft Cla-IVED
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City"Town of
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System Ptimping Record
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DEP lies provided this form for use by local Borards cf Health, Other forms may be used, but the
information must be substantially the carne as that provided here. Before using this form, check with your
local Eoard of Health to determine the form they use, The System Pumping Record must sae submitted to
the loczl Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 16.3511.
A. Facility Information
Important:When
Filling out forms 1 System LoCatto
on tne Computer,
use only the tab qo 0
key to move your Address
'..N. —A
cursor-do not
0
use the return 'd: 111��_i_ MA
key, vy,Tovin -------ate Z__1p"C",...ode,-------
2. Svstepwner_.. ..-__..f_ tet.Nfr:... ..... --�..;�,� �-. �,._. ___ .____.___ ____
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J
Ni rie
Ac cress(if diffe-ent from location)
n State ZlpCode
Telephone Number
B. Fumping Record
1. D31e of F-lumping2. Ouantity Pumped*
Date Gallons
3, Component: M Ce,sspool(s) Tank 0 Tight Tank n Grease Trap
El Other(dascribe):
4, Effluent Tee Filter present? M Yes00
t4 Na If yes, was It cleaned? F-1 Yes No
5, Otserved condition of component F)Llrnped.1/1,
6, 'System I-Durriped By: t2
�D
NI Vie Vehicle License Number
k1find River Environmental
C,)nipany
�—t
7. Location, d:
"jIlinnure o oul'r
pate
oig nature of Roceivfl no Facility(or attach faiiijity receirl) oato
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