HomeMy WebLinkAboutSeptic Pumping Slip - 40 STERLING LANE 11/16/2015 ' ^ ^
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Commonwealth mfR8a � sachusetts
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System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be uaed, but the
information must be substantially the same anthat 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 31OC&1R15.351.
A. Facility Information �
important:When
filling out forms 1. System Location:
on the computer,
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2. System Owner: �u�������2\ ���ET
Name " -- —' ---'- ........
Address(if different from location)---------- -- -- '-- --''-'----------
City/Town State��------'---- ' ----'----------- — �
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B. Pumping Record
1. Date ofPumping 2. Quantity Pumped� / �-�/ ---Gallons 3. Type of system: Cesspool(s) Septic Tank El Tight Tank Grease Trap
L] Other(describe):
4. Effluent Tee Filter present? F] Yes F No |f yes, was itcleaned? El Yes No
5. Condition ofSystem:
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ma�o ��-------- --
Vehicle License Number------
Stewarfs.Septic Service
Company
/. Location where contents were disposed:
Stewa/t'o Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835_____________
aignatureof*avler --�-----'------ --------'--' ------
S�nummofneoeivingFao '- --- — - -' '------ '--- — ' —
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