HomeMy WebLinkAbout- Septic Pumping Slip - 1782 SALEM STREET 6/4/2019 t
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P has provided this fora for use by local Boards of healthy Other forms may he used, but the
information must be substantially the same that provided here. Before using thIl's form,, check with your
local Board of health to determinethe fora they use. The System Pumping ec rmust be,submitted t
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the local Board of Hlealth,or other approving authority within 14 days from the pumping date in
accordance with 3110 CMR 15.351
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fillingg out forms 1 System Location*
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'use nly t tab 1782 Salem Street
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key. Cit,y/Town State ,pup Code
2. System Owner:
Kelly ianc ill
Name
address of different from location)
�tyfrown State ;dip Code
978-8,57-10513
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Telephone Niumber
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B. Pumping Record
531 2 1 QuantityPurnped: 1500,
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. Date of Pumping Date: Gallons
3. Type of system: E], Cesspool(s) Septic Teak El Tight Tank El Grease Trap
Ej Other(describe): _.w.. w.. .m „
. Effluent Tee Filter present' Yes, No, if yes, was it l n d? Yes N
5. Condition of Systeirri:
Good, system ratun properly
6. System Pumpled By:
Jason! Elliott S71 437
Name Vehicle Liciense Number
lvstr and Elliott Services, LLC-DBA Jason ;
Elliott Pumping
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r Location where contents were dis ed.-
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3 2 19
esl lure f Mauler Date
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Signature!of eceiving Facility fate
t5f r .+d e System cur pjn I rrd*Rage 1 of
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