HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 199 OLD CART WAY 7/8/2019 11L
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Syst,ern Pumping Record
Form 4
E1 s provided this form for use by local Boards Health. Other forms may be used, but the
information must be substantially the same as that provided herel. Before using this form, check with your,
local Board of Health to determinethe form tieey use. The System Pumping Record must be submitted t
the local Board of Health or other approving! authority within 14 days from the pumping date in
A., Facility Information
Important;When
w
filling out forms 1. System Location*.
on the computer, �
r
use only the,tad
key to move Your Address
cursor- not 1 . Andover l '1
use the return
„n ..��. � ..... ...mm .. ...
key.
City/Town State Zip Cody m.„ ...
. System Owner:
Name
reran
Address if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
6
1. Date of Pumping 2. Quantity Pumped.-
Date Gal ons
3. Compon nt El, Cesspool(s) Septic Teak 0 Tight Tangy El Grease Trap
Other,(describe)-
Effluent Tee Filter present " " � l I � �� � � it t cleaned? El Yes, El' No5. Observed, condition of component pumpled:
Y
. System Plumped
Name Vehicle License Number
Stwrt's Se tip 58 So. Kimball St., Bradford,,MA
Company
. Location, where contents were disposed,
20 So, Mill Sit., Bradford, MA
Signature f Hauler Date
Signature f Receiving Facility r attach facility receipt)ipt Data
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