HomeMy WebLinkAbout- Septic Pumping Slip - 548 FOREST STREET 12/20/2018 �����������
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HE�L HDERKRT�ENT
Form 4 .
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this fnr0, 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 ur other approving authority within 14 days from the pumping data in
accordance with 310CyNR15.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 548FDREST ST
key m move your xddeue
cursor-do not
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use the mtum --
key. ~'``''~~^ ~~~ ~~~`~~
2. System Owner:
�--� vwLECHANEY
Name
Address(if different from location)
ity/Town State Zip Code
B. Pumping
Record
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11/�O/18 1��O
1. Date ufPunnping 2� Cluandb/ Punopad�
Gallons
3. Component [l Cesspool(s) Z Septic Tank Fl Tight Tank El Grease Trap
R Other(describe):
4. Effluent Tee Filter present? R Yes El No |f yes, was itcleaned? El Yee R No
5. Observed condition of component pumped:
GOOD
8. System Pumped By:
JAY CURRIER H79400
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
11/30/18
Signature of Hauler Date
Signature nr Receiving Facility(or attach facility receipt) ooke
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