HomeMy WebLinkAbout- Septic Pumping Slip - 75 BOSTON STREET 5/2/2019 4k
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DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information n ust be substantially the same as that provided here. Before,using,this form,check with your
local Board of Health t determine the form they use.The System Pumping Record mustbe submItted,to
the local Board ofHealth,or other app roving,authority within 14 days from the pumping date in
accordance with 310 CM 15.351.
I1" Information
Important:When
filling out fors 1. System Location:
n the computer,
use only the tab 7
k t move your ress
, cursor- not �vcl��
use t return Zip Code
W
key'µ cityfTown State
. System Owner:
e
Name
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Address(if d 11 ffle re nt from to cation)
City/Town State Zip Grade
4
Telephone Number
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B. Pumping Record,
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11. Date of Pumping Date" . Quantity Pumped. Gallons
3 C . nent: E] Cessi V s Septic dank El Tight Tank Grease Trip
E] Other(describe)
. Effluent Tee Filter present?. Yes 00/oNo 'If Yes,was it cleaned? Yes El N
5. Observed condition of component pumped,.
6. System Pumped By:
ttl V1 523
Name Vehicle License Number
John Zai Pu
Can
7. Location where contents were dish
6, L 4a S
Sign tuiwe" r Date
Signature Receiving Facility(or attach facility receipt) Date
t5fo 112 " ' Stern Pire Record Page I of'