HomeMy WebLinkAbout- Septic Pumping Slip - 16 OGUNQUIT ROAD 1/22/2019 L Commonwealth of Massachusetts
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City/Town of
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System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Othe"r'fo' r'ms may be used, but the
information must be substantially the same as that 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 local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
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A. Facility Information
Important:When
filling out forms 1 System Location:
on the computer,
use only the tab 161............. U rl e� o
key to move your Address
cursor-do not 4Aot4q� MA 01E
use the return
key. City/Town State Zip Code
2. System Owner:
tab
Name
lBNfA
Address(if different from location)
City/Town State Zip Code
I — 1) 0
Telephone Number
B. Pumping Record
,J 3
1. Date of Pumping 19 2, Quantity Pumped:
Date Gallons
3. Component: F-1 Cesspool(s) eptic Tank Tight Tank El Grease Trap
Other(describe): ...........
4. Effluent Tee Filter present? El Ye�_d'No If yes, was it cleaned? n Yes Ej No
5. Observed condition of component umped.A.
—-------------------- ------
6. Systerp,PUmped By- 41
f 0
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St:, Bradford,MA Z
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Company
7. Location where contents were disposed:
20 o. Mill St., dford, MA
----t" - 5+
Haule-v_
0 o' Mill
/Y
Sign_g� Lure of ..........
ig—n- ture of Haule Date
nature of Receiving Facility(or attach facility receipt) Date
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