HomeMy WebLinkAbout- Septic Pumping Slip - 38 WHITE BIRCH LANE 12/12/2018 Commonwealth of Massachusetts
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«�nm��u� Pumping
Record
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Form
DEP has provided this form for use by local Boards of Heolth. Other forms may be used, bu±Ule
information must be substantially the same aa that provided here. Before using this form, check with your
local Board of Health bo determine the form they use, The System Pumping Record must besubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCk8R15.SS1
A. Facility Information
Important:When
filling out forms 1. System Location:
un the computer, /
use only the tab 3
key ho move your Address
cursor-do not
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umatheodum �
key. City/Town State Zip Code
2. System Owner:
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Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date ofPumping 2. QuDateantity Punn��d� ~
3. Component: [l Cesspool(s) GepticTank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? R Yea E� No If yes, was it cleaned? ��N
-. Observed condition — component pumped:
6. System
Name Vehicle License Number
Stewart'Stewart's Septic 58 So. Kimball S fo
Company
7. Location where contents were disposed:
20 S Bradford,
Signatu;reof
u/gnauureo,Receiving Facility(or attach facility receipt) Date