HomeMy WebLinkAboutSeptic Pumping Slip - 16 CARLTON LANE 11/16/2015 - - '
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System Pumping Rec ord '
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be,uoed, but the
information must bo substantially the same aethat 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 |000| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CK4R15.351.
A. Facility Information l
Important:When /
filling out forms 1. System Location:
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use the return N— ----- -------- ' ------
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2. System Owner:
Name � ----- -----------------'
--� Address(if different from location)--------------------
City/Town ������-�-------'-'--- --- State------------ — Code
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B. Pumping Record
/. Date cvPumping Z� Quantity Pumped:
Date ------ �
8&|ions -
1 Type of system: [] (s) & Septic Tank F-� Tight Tank 0 Grease Trap
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Other(describe)- -------'-------------------------'-----
4. Effluent Tee Filter present? Yes Fl No If yes, was ho[eaned? Yes No
5. Condition of System:
---------- --.......... ...........
6 System Pumped
Vehicle License Number
... --- - -_ . _
Company
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7. Location where contents were disposed: �
Stewort'o Pre-treatment Plant, 20 So. Mill Bradford, MaO1835_____________
Signam�nfHau�r ���------------'- Da�-----'''-'' ----'- --
��nommvfnoueimng �um� ----- --- --'--' 'Da"te----- '------ - ---
om��c-03/06 System Pumping Record-Page 1 of 1