HomeMy WebLinkAbout- Septic Pumping Slip - 250 ABBOTT STREET 6/10/2019 "-%--%1th Commonwua,
o Massachusetts
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Clity/Town
System Pumping Record
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P has, provided this form for use by local Boards of'Health. Other forms may be, used, but the
information rust be substantially the same as s that provided here,. 'Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted t
the local Board of Health or other approving uthorit within 14 days from the pumping date in J
accordance with 310 CMR 15.351.
A. Facility Information
Important: the
filling out forms 1 M Bataan . ti+ ".'
on the computer
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use only the tad "
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It /Town State Zip Code
2. System,Owner:
rill
Name
RAW
' r r>(if different from location)
Cit /Towin State Zip Code
TelephoneNumber
B. Pumping Record
. 'Date of Pumping Date ° . Quantity Pumped: Gallons
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3. Component: Cesspool(s) Septic Teak Tight Tan � Gr se �'r
D Other(describe):
,. Effluent Tee Filter present,? Yes No if yes, was it cleaned'?, Yes N
5. Observed condition of component pumped:
. Syste Plu ed By:
1
Name Vehicle License Number
Stewart's Se tic 58 So. Kimball' St.,
Company.
M. Location where contents were is s v
2 S . Mill St., Bradford, MA
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..........
Date
Signature of'R,eceiving Facility r attach facility receipt) Date
t for . • 1/ 2 System Purnping record Page 1, of 1