HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 8/17/2015 � ^ ^
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O 9O�m Pumping Record
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DEP |as provided this form for use by local Boards of Health. Other forms may be used. butthe
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 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
fi||ingout forms 1� System Location:
on the computer,
use only the tab
key x,move your auunamo - ----------
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use the m�m �h Andover ---------- ...--
key. ,/u*n State Zip Code
2. Syat* � & &
Name / / � �------ --'-----------------------------
��------ AddresaVfumenantonmlooation—
--'------- -----'----'------------'---- �
^"r'°w' State Zip Code
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B. Pumping "~~c="d
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R+ /� _/ '�
1. Date of Pumping 2� Q��� Pumped.- - --
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3. Type ofsystem: |l (a) Septic Tank F-1 Tight Tank E] Grease Trap
\
[l Other : -----'-'-------------'--'--------- -'------ __ !
4. Effluent Tee Filter present? Fl Yes F] No |f yes, was' if cleaned? F Yes R No
5. Condition of System: /l/-�
W �
6. System Pumped By: |
|
|
Name ���---------- --'------'-----'------ |
Vehicle License Number
Stewart' Septic
Company ��----------- --- '--
T Location where contents were disposed:
Stewert'o Pre-treatment Plant, 20 So. Mill Bradford, MaO1835 _______________ _
Signature nfHauler ���-------------- -��------''-'' ----'- --
Signature of Receiving Facility--- -- - - '---' ' Date--------- -- '----------------
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System Pumping Record`Page 1m1