HomeMy WebLinkAboutSeptic Pumping Slip - 166 GRANVILLE LANE 12/8/2015 '
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Commonwealth of Ma � sachusett `
City/Town of North A d
[ ler
System Pumping '
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Form 4
DEP has provided this form for use by local Boards of Health. Other forms may beuo�d but the
infnmnat�nmust beaubeLan�aUy the same aathatprov�edhena� Beforeusingthia --- check w�hyour
local Board of Health to determine the form they use. The SyntamPumping Record m .` bmaubmi�edto
the local Board of Health or other approving authority within 14 days from the pumping -'date in
accordance vvith31OCyWR15.351. `
. ` A. Facility oxnooxxxxatUoKV �
Important:`wmon
filling out forms 1 System Location: <
on the computer'
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�ymm�eynur `�~�^ '-------- ---'-----' - ----------------
cursor'uonot
North use me�mm `'^ '^'""`"' __-___-'-- --- ' --' - '---------'-- ------'-----'----
key. City/Town State Zip Code
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2. System Owner: &
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_Name �-� ------------ - --'- --' -'----------------'----------------
Addmsu(Ifdiffe rent�nnmcation'------- - ------ ---------------'----'------------
Z�yn�*n ��----- '------' - ' --------------'-- --------------- �
mo� zipOo�a
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TeI nowvr�u e F------- �
B. Pumping Record
1� Date ofPumping l��-J���- 2� Quantity --Gallons 3. Type of system: El Cesspool(s) Septic Tank � Tight Tank � Grease Trap
L]
Other -
4. Effluent Tee Filter present? 0 Yes Ej No If yes, was it cleaned? Fj Yes F-1 No
5. CondiUonnfSya&em-
- -/~-~^ Pumped By:
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m�e /---- _Ve h�Ic I eI -en-s'e-_N_u'm be-r---- �
Sh*wart'a Septic Service
Company ------ -'- --
7. Location where contents were disposed:
"u,wa/txr/ Bradford, Ma 01835
oignomenfnaule, _---'--------- --------' '-' ' ----------------'
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o�oamnavfReue/mng��6--'---- -'---- ---- - ---
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