HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 5/8/2019 u
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` System Pump'lingRecord j
Form 4
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D,EPI as provided this form for use, local Boards of Health. Other forms may be used, but the
information mast be substantially the same as that provided here. Before using this fora, check with your
local Roam of Health to determine the fora they use., The System Pimping Record rust be,submitted r fitted to, t
the local Board of health or other approving authority within 114 days from the pumping date In
acco rd a,n c,e with 310, CMR. 15.3 5 1.
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A. Facility Information
Imt:When
filling out forms 1. System Location
on the computer,
use only the tad
key to move your Address
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cursor-do not 6,- Leu-)tl � MA 6
9
use the return
key. City/Town State Zip Code
2. System Owner. .
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Name
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Ad r es if different from location)
City/Town State Zip Code
...............................................
Telephone Number
ry
B. Pumping Record
1. Date Pumping Date
�. 2, Quantity Pumped# Gallons
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3. Component: El, Cesspool(s) E] Septic Tank Fight Tank, E36rease Tra,
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Other(describe),:
. Effluent Tee Filter resent' Yes [:1 No if yes, was it cleane Yes No
5. Observed condition of component n + :
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6. System P urn le :
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St wart's. Septic 58 So. Kimball St., Bradfor ,M'A
Company
1.
. Location where contents were disposed:
20 S lull St., Bradford, MA
Signature of Hauler Date
Signature f' i ing Facility(or attac-h facility receipt) Date
t5f r°u . + * 11 2 System urnn in Record Page 1 of 1