HomeMy WebLinkAbout- Septic Pumping Slip - 835 CHESTNUT STREET 10/3/2018 Commonwec lth o Cifi
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DEP has providod this farm for use by local Boards of Health, Other forms.may be used, but the.
Information must be substantially the s;irne as then 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 to
the Iccol Board of Health or other approving atithbrity within 14 days from the pumping date in
accordance with 310 C,MR 15.351.
K Facility Information
Important;When
filling out fors 1. System t.oc ati n.
an the computer, t C
use only the tab
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key to move your Aldress _..._..rr ,._
cursor-do not �� }�/
useMA
the return ('ikyll own .— .. - ......:_. State ZIP Code`"m..
key
z. System Owner.
AdJresa(if diffi�rant front lar±a#ton}
t;lty/Town State Zip�Code �—
Telephone Number
S. Flumping Roo-orc
'' p '_"1 fir; � ,,
1. L}Clte of Pumping Date — 2, +*uantity Pumped,
Gallons
3. Component: (l Cesspool(!") 'Septic Tank ❑ Tight Tank, CI Gre0se Trap
[ Other(describe):
4. [=ftluent Tee Filter present? Fl Yes No If yes; was it cleaned? Q Yes No
5. Observed condition of component pumped:
1
s, ;>yste ., dBy: � �✓
Pkame Vehicle License Number
1r,lind River l:nvirorlrnental i
Company__ ... _ 'OSVii Chlil V VV
TP
7. Location whare contents were disposed: 8 Porter St
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5, ore aE h�ulerCiak
&ghsture of Riiicelvifig Fs jilty(or attach faa,llity r®r,"ePl ) bake
t6f6rm4.doc• 11112 System Pumping Recor+i•Page 1 of 1