HomeMy WebLinkAboutSeptic Pumping Slip - 45 SUGARCANE LANE 8/12/2015 . `
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Form 4 |<ORrHANDOYER
DEP has provided this form for use by local Boards of Health. Other forms may beused, butt
he
information must be substantially the same aethat provided here. Before using this form, check
with yo/
local Board of Health to determine the form they use. The System Pumping Record must be Submitted i
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CWR 15.351.
A. Facility Information �
Important:When |
filling out forms 1. System Location:
on the computer, �� /
use only the tab _L
key m move your Address - -^-'-~~-----------''--------' -' ------------------
uumu,-uonot
use the return North Andover _________�_____ _�___ __�_ __ _________ �_______________
key. ~�''"='' State Zip Code
2. System Owner: � &
bf
Nama \J ` ------ ---'-----'-_-----'-----
xddmv (ifoifferent fror�wcatjor�_------- ----'� -- -
cityFrnwn ----'------------ —State' Zip Code �
B. Pumping Record
1. DnteofPumpinQ L �� ' '- -- 2 (]uantity �umped� --- �
3. Type ofsystem: El Cesspool(s) " SeptioTenk F-1 Tight Tank El Grease Trap
El Other(describe): -__'----'----
`
4. Effluent Tee Filter present? Fl Yes F No If yes, w s ` cleaned? 0Yes F� No
5 Condition of System: -ood
Name
Vehicle License Number
Ic
- /. Location where contents were disposed: �
S*�' � � n i nd, |
Ma
ure of Ha r ��.. �����'��
Date
Sig y ----_ -- - '_--_
c��==--~``'~'�' "°"� Date
t5fmm �c-03/06
System Pumping Record-Page 1 of 1