HomeMy WebLinkAbout- Septic Pumping Slip - 45 WHITE BIRCH LANE 12/12/2018 Commonwealth of Massachusetts
ity[Town of No
SYStem Pumping .
Forms I; �
DEP has provided this form for use by local Beards of Health. Other forms may be used, but the
information must be substantially the same as that provided hare. 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 local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.361,
A. Facility Information
Important:When
tilling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
curthe
- not
use (�
use the return MACI /Town
key. ty Skate Zip Code
2. System Owner: �.._.,
—, toy eatP
edema
Address(lf different from location}
City/Town State Zip Code
Telephone Number
B. Pumping cor
1. Date of Pumping " l a � �
Date
p 9 2, Quantity Pumped:
f3allons
3. Component: ❑ Cesspool($) Septic Tank ❑ Tight Tank ® Grease'Trap
® Other(describe):
4. Effluent Tee Filter present? ® Yes No If yes, as it cleaned? ❑ Yes blNo
5. Observed condition of component pumped:/1
6. Sy m Pumped By:•�
Name Vehicle License Plumber
Stewarrs Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. iil t. Bradord. MA
nature of Hai
g ul r Date
Signature of Receiving Facility(or attach facility receipt) Date
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