HomeMy WebLinkAbout- Septic Pumping Slip - 851 JOHNSON STREET 5/8/2019 Commonwealth of Massachusetts
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Cit,y/Town o
System Pumping
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Form 4
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F has provided this form for use localBoards of Health, Other forms, may e used, but e
information must be substantially t'h�e same as that provided here. Before using this form, check with your
local Board of Health to determinethe form they use., The System Pumping Record rust be submitted t
the local Board of Healthy or other approving authority within 114 days from the pumping date in
accordance with 310 C R 15 3151
A. Facellity Information
Important:When
filling out forms 1 System Location:
on the computer,
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use n�i h �
key to move your Ake
ursor-do,not 01985
use the return .. .mm.......,,,
City/Town/Trn State
lw.
2. System Owner:
VIQ
00 Name
......... ..,w ....... ...m m.rvm......n.nmm.nmmnnnm,m..�m .... mn.�..�
Address(if different from location)
City/Town Status Zip Cod
Telephone lurnhr
B. Pumping Riecoird
1' [date of PumpingDate 2. Quantity Pumped'. Gallons
3. Component: El Cess 1 s El S ti'c Tan TTight Tank, Grease Trap
Other(describe): .. �m
(fluent Tee Filter present? El Yes If yes, was it cleaned? es [:1 No
5. Observed condition of component pumped:
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6e Bata Pumped By:
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Namur 'Vehicle License Number
St w nut's Septic 5 S Kimball ,fit., ra t r ,MA
m m. .. ....
Cn�mn
7. Location where nt nts,were disposed:
2 So. Mil St., Bradford, MA
...........
Sig n turV6 Ha, I eir r [date
Signature of Receiving Facility(or attach facility receipt) fit+
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