HomeMy WebLinkAboutSeptic Pumping Slip - 19 BRADFORD STREET 11/16/2015 . �
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System Pumping Record '
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may be uaed, but the
information must be substantially the eemo 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 310 CK8R 15351
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A. Facility Information
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filling out forms 1. System Location: ""*
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2. System Owner 4,
Name --~—'---- --------- ----'------------'---
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Address(if different from
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CityfTmwn �����------------'------�-- � '- State------------ Zip Code
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B. Pumping Record
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i. Date ofPumping ----'°`��~—=--- 2 Quantity — / ��w�' ----
Date � � SoUono
3. Type of system� D Cesspool(s) 0O Septic Tank Tight Tank El Grease Trap |
LJ Other : ......
� Effluent Tee Filter present? D Yes O No |f yes, was it cleaned? Yes No
5. Condition of System:
......................
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O. System Pumped By:
----
Name ---'------------
Vehicle License Number
Stewart's Septic Service
Company ��------- --- '--
7. Location where contents were disposed:
5tewart'n Pre-treatment Plant, 20 So. WliU Bradford, Ma 01835 ____________ _
Signature ofHauler Date'----'''—' ------ --
Signature ufReoewnopamx� ----- — '—'-- ���----'----- —
omrm*�c-03/06 System Pumping Record-Page 1 of 1