HomeMy WebLinkAboutSeptic Pumping Slip - 26 Stonecleave - Septic Pumping Slip - 26 STONECLEAVE ROAD 11/1/2024 Commonwealth of K8assachLisetfs
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System Pumping Record
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DEP has provided this form for use by local Bowrda of Health, Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form {hey use, The System Pumping Record must be Submitted k}
the local Board Of Health or other approving authority within 14 days from the pumping date in
accordance with 31DCMR 15361
A. FaC'|^fy )nforMMaf'(JU BWLDING� front side rear left —right
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T�fephone Number
B. Pumping Record
�ale Gallons
3, Component: 77 Ceospoo|(a) Septic Tank Tight Tank Grease Trap
�l Other (describe):
4, EfMuentTee Filter present? F� Yes No |f yes, was (tcleaned? El Yea [I No
b, Dbn*weU condition of component pumped:
8. Syatem Pumped By:
Dave T|ne
wamo vex�/ouconoewum
Bate Bateson Enterprises, Inc,
T disposed:
GLSD
Signatuce of Hauler Date iL
Signature of RecelvIng"Facility(or atlach facility receipt) Date
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