HomeMy WebLinkAboutSeptic Pumping Slip - 288 FOSTER STREET 11/16/2015 � .
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Commonwealth wf*ma�sachusefts
C~+n/T��� of North A oVer
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be,used, but the
information must be substantially the same 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 mr other approving authority within 14 days from the pumping date in
accordance with 31UCK8R16.351.
A. Facility Information
Important:When
filling out forms 1. System Location: �
on the computer,
use only the tab ________
key m move your Address
cursor'donot N— ---- ---'—'-- - --'------m�+--^ J
use the return —
-----------'----
City/Town 0a� Zip
2. System Owner:
Name
�--~�--'
Address����---------------------'--------' �
(if different from location)
CityfTcwn ---------- -- State------------ —ovda
-- --'
Telephone Number �
B. Pumping Record �
`
1. Date of Pumping 2 Quantity Pumped: --- �
Date � � Gallons .
�
3. Type ofsystem: Fl bd Septic Tank [l Tight Tank El Grease Trap
[l
Other(describe)- -----'—'------------'------------'----- --
4. Effluent Tee Filter present? [7 Yes No If yes, was if cleaned? Yes E] No
5. Condition ofSystem:
0. System P
xa I"Na Vehicle License Number
Stewart's Septic Service
Company ��----'---- --- - -- �
7. Location where contents were disposed:
Gtewert'm Pre-treatment Plant, 20 So. Mill Bradford, MaO1835 _____________
Signature ofHauler ����------------- Date------'-- ' ------ --
S�nam^aufRecei�ngp*om� ----- -- '---- ' ���----- ---''-- --
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