HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 9/21/2018 |
Commonwealth �� R�Massachusetts
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System Pumping Record
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Form T
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must bosubstantially the same as that provided here. Before using this form, check with you/
|ncg| Board of Health to determine the form they use. The System Pumping Record must besubmitted to
the local Board of Health orother approving authority within 14 days from the pumping date in
accordance with 310 CK0R 15.351.
A~ Facility Information
Important:When
filling out fnnne 1, System Location:
unthe computer, `
use only the tab
key mmove your Address
cursor-do not
No. And MA 01
uxethenetum
key, City/Town 3mava Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date ofPumping � (]uantityPunnped�
o�o � ' Gallons
3. Component: El Cesspool(s) [l Septic Tank Tight Tank [7 Grease Trap
ZrOther(describe): —
4. Effluent Tee Filter present? Fl Yes E'Nu |fyes, was itcleaned? n Yes M No
5. Observed condition ofcomponent pumped:
G. System Pumped By:
NAme Vehicte License Number
Stewart's Septic 58S Kimball St Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill G Bradford, [NA
SiQnutureofHeu|ar Date
S|gnoture of Receiving Facility(or attach facility receipt) Date
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