HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 38 WELLINGTON WAY 7/16/2019 M
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ANDOVEKSystem Pumping Record
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Form 4
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DEP has provided this form,for use by local Boards of Health. Other forms may �I. �� � but the
information must be substantially the same as,that provided here. Before usling this form, check with your
local, 'Board of Health to determinethe form they use. The System Pumping Record rust be submitted t
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 3110 CAR 15.351.
A. Facility Information
Important: When
tilling out.forms 1 System Location:
on the,computer,
use only the tab 36.. �.,
key to move your Address
cursor- notthe return H V A 5
usefit /T wn State1.11, I'll,iI'll "I Code,
key.
. System Owner*
I
JAMES, SCARPONE
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Address(if
different r m location)
C t /T own State Zip Code
TN + ru 1ur
B. Pumping Record
1. Date of Pumping 7 9 . Quantity Puy 5
00
Date Gallons
I Component: C ss I s Septic Teak ®i Tight Tank El grease Trap
[I Other(describe)
4. Effluent Tee Filter present? Ej Yes El No Ifyes,,,, was it Ian Yes E] No
5 Observed condition of component pumped.
FOOD
6. System Pumped By,-.
SAY CURRIER H ,
Name a License Number
J'S SEPTIC& DRAIN
Company.
. Location r ntents,were disposed:
G LS
7/10/19
91nature of Hauler Date
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t5foirm4.doce,11/12 System Pumping Record*Page I of I