HomeMy WebLinkAbout- Septic Pumping Slip - 124 PENNI LANE 5/8/2019 OHM
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DEP has pr ^ idled 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. Before using this fora, check with your
local' Board of Health to determinethe form they use. The System Pumping Record must be submitted t s
the local Board of Health or other approving authori,ty,within 14 days from the pumping date in r
acco rdance with 310 C R 15.351.
A. Facility Information
IMPorta f:When
filling Brut forms 1, System; Location:
on the computer,
use only the tad p
key to rnove your Address
cursor-do not Andover A
use thereturn „n. .- ..mm mm.. . .�
Cit,y/Town State Zip Code
2. System Owner:
Name
VQ
different from location)
City/Town Mate Zip Code
Telephone Number
R. Pumpli'ng Record
1. Date of Pumping, 2. Q laity e
Date Gallons
3. Component: cesspool(s) Tank 0 Tight Tank El Grades Trap
E] Other(describe)-, . ... .v ., . . .,ry.,..-.... .. ..... .w . . mm
4. IEffluent Tee Filter present? ' es No If yes, was it cleaned Yes No
4 Observed condition of component pumped:
6. System Pumped ,
Name Vehicle,License Number
St wart's S tic 58 l im ll St., r a f r
m... . _.... .m -
Company
T L ca i In where contents were dispose
20 S . Mill St. Bradford, MA J
y
Signature of Hauler Cate
Signature of'Receiving Facility or attach facility receipt) Date
t5fo rm 4.d o n.11 121 Systern Pumping Record Page 1 f 11
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