HomeMy WebLinkAbout- Septic Pumping Slip - 47 BOXFORD STREET 6/10/2019 V
uommonwt,:-,-aa1th of Massachusetts, , r
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City/Town
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System Pumping Record
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ll`Form 4
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CEP has provided this,fora for use by local Beards of Health. Other forms may be used, but the
information must be substantially the same s that provided here. Before using this form, check with your
local Board Health determine the form they use. The System Pumping Record must be submitted
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the local Boardof'Health r other approving authoritywithin 14 days from the pumping date in
A. Facility
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B. Pumping Record
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1. Date of Pumping Cate Quantity Pumped: Gallons,
3. Component: Cesspool(s) [kpeptic Tank Tight Tank El Grease Trap
Other (describe)-
4. ,m . . v ., . . ; . n ... .
Effluent Tele Fifter present? Yes No if yes, was It cleaned? Yes No
51. Observed condition component pumped:
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6. System prod fame Vehicle 1
Licenser r _.
Stew rt's Septic 58 So. Kimball St. Bradford,MA
Company
. Location where contents were disposed:
20 Sow Mill St.,Brad or ,,, M
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Signature of au er Date
Signature of Receiving Facility flit r attach facility receipt) Date
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