HomeMy WebLinkAbout- Septic Pumping Slip - 34 WILD ROSE DRIVE 5/8/2019 rojo;
Commonwealth o assa,chses,
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system Pumping Record, W
Form
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. i
ith your
local Board of Health to determinethe fora they use.The,System Pumping Record must be submitted t
the local Board of Health or ot,heir approving authority within 14 days from the pumping date I
A. Facility Information
Ire
When filling out I. System io
forms o
,computer',
only the,tab key► �d'-PJ
,.
t y ur �
cur not
use the return 6hy state .... . Zip Code
'key.,
2. System Owner-,
—AL Name
Address,"(1f different from locauton)
!4«
OWT `.
State Z,ip Code
Telepho'ne Number
Ba, PUM, Ping Record
I Date of Pumping
ate Galion
3. Type of system: El Cesspool 455S�eptic nk El Tight T
ank El Grease,Trap
&(Other(describe):
. Effluent Tee Filter present? Yes 0 No If Yes,,was It cleaned? Yes No
5. Condition System;
1
6.
System i
NayweIry
_.
Vehicle Limas Number
16. ff P 2M C4 Q
cow
" Location where contents were is
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w
Sl reof Hauler Dar
Signature of Receiving Faclifty Date,
System Pumping Record Page