HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 37 OLYMPIC LANE 12/19/2024 �����/
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System Pumping Record
Form 4 F�`:_�c4t/7 D_Partrn �
OEP has provided this form for use by local Boards of Health. {}Lherfo/nnamay be used, but 1 �»��
information must be substantially the same as that provided here. Before using ihia harm, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted in
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CK8R 15.351
HOUSE: front a C� ide rear left
A. Facility |ylfOym23f'On BUILDING: front back side rear left
Important:When DECK: under
m|m0 out forms 1, System Location:
on the computer,
Lisa only the tab
�y�move your �AVmo^ - `
oomo,-uonm MAC/
use mom\u,n — ^ �
key, ~'^,''`~^ =,`= Zip Ccmv
2. System Owner:
Address(if different from
&0A
Qty[Tvwn3 t Zip Code
Telpho�, umber
B. Pumping Record
1, Date of Pumping ate 2. Qu2ntity Pumped, Gallons
3, Component: Ces6pool(s) Septic Tank Tight Tank Grease Trap
4, Effluent Tee Filter present? Fl Yee No )f yes, was itcleaned? [] Yes Fl No
5. Observed condition of component pumped:
O, System Pumped By.
TIney ass 1��95Q V12SS I AD31Z
eateson
Company
7. i
GIL
Signature of RecelvIng acility(or attach facility receipt) Date
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