HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 135 FOSTER STREET 12/30/2024 ���
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System Pumping Record
7 207
Form 4
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DEP has provided this form for use by |ooe| Boards of Health, Othor forms 9^~' �� ftm�t t the
information must be substantially the same as that provided here. Before uain' this form, check with your
local Board of Health to determine the form they use, The System Pumping Record must be submitted to
the local Board Of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCK8R 15.351
HOUSE: frontrjLa"c:k) side rear left (FDT
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key tomovoYour -Address
cursor do riot
Kn�
use the re
turn
key. City/Town= Zip Code
2. System Owner:
21 El�I
N1A
City/Town t ate (r Zip Code
B. Pumping Record
4_____ 2. Quantity Pumped, Gallons
3, Component: Cesspool(s) Septic Ta n k L] Tight Tank [I Grease Trap
4, Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? 0 Yee No
5, Observed condition of component pumped.
6, System Pumped By,
OmveT|ne
Name Vehicle License
eateson EntqTrises,Company
7, L 'on where contents were disposed,
GLSD
Signatufe of Hauler Date
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