HomeMy WebLinkAbout- Septic Pumping Slip - 210 GRANVILLE LANE 5/29/2019 ✓✓�li✓✓rn�UJAPI i1l✓m."K f �i✓✓w✓cur✓,;
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System1,
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pingPum Record0
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DEP
has provided this form for use by local Bolards of Health,Other forms may be used,but,the
Informetion must be,substantially the same as that provided here,,Elefore using this form check with,your
local Board of Health to,determine the Form they use,,The System Pumping Recordmust be submitted to
the'local Board of Health or'Other approving authority within 14,days from thie pumping date In
accordancewith 310 CM R I 6l.351
A. Facilit
y
Information
important#When.
I'l I
11ing out forms 1, System Location,
n the computer,
use only the,tab
key to,move your, Address
cursor-do not
use the return �41 A
City/Town State Zip 11 Code 914
.A Ali
Name
" If different from location)
City/TownState
Zip Code
Jid
Telephone Number
B. Plumping, corgi
I. M ,
Date of Pumping
Date 2. Quantity Pumped
W"
Gallons
3jw Component. Septic Tank
Tight Tank Grease Trap
El Other(describe):
41 Effluent Too Filter present? 0 Yes No
I s,,'w s It cleaned?
I N
i
6. Observed condition of component l rn ,
SYsteM Pumped y
DaI
Name
Vohlcle Llae—n—sa-1MtZ±
1
7. Location wh
e,4, 044 w t4o,sed:
J)
(� -
Slignature ouir,
Date
i r turo OF Roloolvino Fool i
t for w o 11/12
S' tem Pumping record o page 1 of