HomeMy WebLinkAboutSeptic Pumping Slip - 95 OLD CART WAY 8/31/2015 . . - '
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Pumping Record
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Form TOY�OFNoRN;/��)VEK
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DEP has provided this funn for use by local Buende of Health. Other forms may be uaed, butthe
information must be substantially the same as that provided hone. 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 \nma| Board of Health or other approving authority within 14 days from the pumping dote in
accordance with 31UCK8R15.351.
A. Facility Information
Important:When �
filling out forms 1 System Location:
on the computer,
use only the tab -
key to move your Address '
cumor-dorot
use the return ''— ----- ..........--_-
xoy ur«/v°» mmo Zip Code
3. System Owner:
Name - �x�/�--l-----------'-- -----------'
--------
Address(if different from�oahun --------'-- - '-------''----------'
City/Town ��---------'---- '-' State------------- --Code
Te�nhonowvmbe
B. Pumping Record �
1. Date ofPumping --------�'-- 2 Qu��� Pum��� --
Date � Gallons
3. Type ofsystem: El Cesspool(s) septic Tonk El Tight Tank Fl Grease Trap �
k
Fl Other(describe): -----'—'------------'--'----..... ---'--'-- ------- --
4. Effluent Tee Filter present? Yes No If yes, was if cleaned? R Yes F� No
b. Condition ofSystem: | /
��---''-------'----'-------------- |
�
& �
�
Name Vehicle License Number --
Stewart'a Septic Service
Company
7, Location where contents were disposed:
StevverCe Pre-treatment Plant, 20 So. Mill Bradford, MaO1835 ________________
Signature ofHauler ��--------------' --,------'--' ------
Signature ofReceiving poo �---'-- —'- '---' ' '------------ ' -----------
�plity Date
umm4��03/06
System Pumping Record'Page 1 of 1