HomeMy WebLinkAbout- Septic Pumping Slip - 71 CANDLESTICK ROAD 7/8/2019 Commonwealth of Massachusetts F,'ZMCE'1,VED
City/Town of No.
System -j
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E has provided this fora for use by local Board's,of Health. Other forms may be used, brut the
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information must be substantially the,same as that provided here. Before using this form, check with cur
local Board of Health to determ,ine,tl e form they use. The System Purniping Record gust be submitted t
the local Board of Health or other approving aut rit within 14 days frorn'the pumping date in
A. Facility Information
Important:When
filling out forms 1. SIystem Location:
on the computer,
use, rl the tad ... ,
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key to move your Address
err-do rust r� ' �r �I
use .the return ....m �.,�.. ry
845
key. City[Town State Zip Code
2. System Owner'.
em
Name
Run
.. .
,Address(if different from location)
City/Town ;state Zip Code
Telephone Number
B. Pumping Record
1 Date of Purnping
Date allona
34 Component: E] C ss o I sE<CSepticTank El Tight Tank Grease Trap
E] Other(describe): . ,, .... „mm,. ,.,. .....
. Effluent Tee Fifter resat " Yes ON o It yes, was it clean ' Yes N
5. Observed condition mponent pumped:
. System P ed By:
cu,
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NamVehicle License Nu r
q 58 So. Kimball fit., B,radford,MA
Company
7. L,oIcation where contents were disposed:
20 So. Mill St., adford, MA
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Sb..I..........�tau er Date
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Signature of Receiving Facility( r attach facility receipt), late
t5f rm .dcc-1 /12 System Pumping in Record Page 1 of 1