HomeMy WebLinkAbout- Septic Pumping Slip - 143 LIBERTY STREET 6/27/2019 �r
COMMonwealthRECEIVED
City/Town of t
System P Ani(Xtr
Fortri 4 Umping Record TOWN
OF NORTH
DEPARTMENTHEALTH
DEP has PInformationrovided this form
substantiallyMust be a1s Other fir M
o
local 810ard of Health to determine the t
'the local Board of Health or'other r use,The this form,,check with your
r Record mushbe submitted to
accordancewith 3 M w3 m the PUMpIng date In
As
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filling out forms o Ssm Location:
on the computer,
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key CI(YfTowns
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2s System Owner; ZIp Code
b
A00
J
ress,(if different from location
Cat _
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Zip Code
ln Number
B. Pumping Reco"'rd-i,
1 Date Of Pumping
Date2. QuantityPumped,
lilons
01
3. Componento '30
I Ic Tank El Tight'Tank Ej Grease Trap
Other(d'escribe): ....
t
Effluent Tee,Filter present? yes Ni
If Y8s,was It cleaned? yes Cj N
Observed condition Ofcomponent
S. System Pumped
Name, 9
service, ),11,aln, " w ;M Vehicle License Number
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Company 11,111,11,Reading,MA 01 4
70 Location where contents were
r
ure of,Hatiller, r
SIP911WO Of R4,041vin, Foollityt c w facility receipt) Date
System Pu mpling Record