HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 8/7/2015 - - - '
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Form 4
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DEP has provided this fuxn for use by local Boards of Health. Other forms may be uaed, but the
information must be substantially the same as that provided hero. Before using this fonn, 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 310CyWR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
nn the computer, ._J_
use un��e�b ,_-__'_�__-_-___--___-_--_'' _ ---'-------------- �
w�mmmmyour pmu��
uumo,-donnt
North- h
------------- ---�'---- - --'____-__-__'-_
key. Cwv/mwn State Zip Code
2. System Owner:
_
mame
,
-------- xddressVfdifferent frnm|ovaovn—
--'---- -'- '---- -------------------------------
Q��nwn ������-�----- '--�-'--'-' - �St��'-------------�� Zip Code----------- !
Te �� ������� �
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B. Pumping "=~~~~^"~"
1. Date of Pumping /--I _.5
...... 2 Quantity - ---
Date � � Gallons
3. Type ofsystem: |(s) Septic Tank F-1 Tight Tank El Grease Trap �
E] Other(describe): -------'-------------'------------
---'-'------ --
4. Effluent Tee Filter present? F� Yes El No If yes, was if cleaned? F Yes No
5. Condition ufSyatem�
5. System Pumped By:
-__'-
Name Vehicle License Number
Stewart' Septic
Company �---------- '-' '- '
7. Location where contents were disposed:
3tovvaryn Pre-treatment Plant, 20 So Mill Bradford, Ma 01835_____________
Signature ofHauler Date-----'-- ------
S�nam�nfueoew�o rac|���----- '---' ' '----------'-- -'--------------
�m� Date
���4.doc-03/06
System Pumping Record'Page 1 m1