HomeMy WebLinkAbout- Septic Pumping Slip - 5/8/2019 RECEIVED
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Commonwealth of' MassaIIII
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City/T'own
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System Pump' Record
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DEP has provided this form for use by local Boards of Health. Other-forms may be used,but the
information must be substantially the setae as that provided!here. Before using this fora„check with your
local Board of Health to determine in the form,they use. The System Purriping Record must be submitted to
the toBoard Health or other approving authority within 14 days from the pumping date n
A. Faciality Information
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When filling out 1. SystemLocation.,
fbrms,on the
computer,,use osw
only the tab key Address y
to move your .
cursoir-do,not
use the return Cit "' w state _ro
Zip Code
2. System a r4
MWIS �,t's (_0
Name
I
Address"(if different from location)
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ito !j State Zip,Cody
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6 5--D
Telephone Number
B. Pump"ng Record
1. Date of'Purnping t 2. Quantity Pumped --
3. Type of system., [I Gesspallons'
fight Tank EIGrease Trap
Other(describe):
t
4.
Efflu ent Tee Filter present? Ej Yes No If yes,was,it cleaned? [:1 'Yes 0 No
5. Condition of System:
6. System Pump
N a8m Vehicle License Number
� �p,
'. Locat re contents were disposed:
lie
rt
Signa ure of Hauler
Date,
Signature of Receiving Faclifity
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PumpingSystem r ' Page I of
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