HomeMy WebLinkAboutSeptic Pumping Slip - 173 RALEIGH TAVERN LANE 12/8/2015 - ~
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Commonwealth mfK8a � sachusetts
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City/Town L�VVY� wo uv[)/ �o / ^`�lv^C}ver
System Pumping Record '
DEP has provided this form for use by local Boards of Health. Other forms may be ueed, but the
information must be 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 local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 3i0CKxR15.351.
A. Facility Information
Important:When
f0 1. System Location.-
on the computer,
use only the tab
key m move your Address -'----�---~~�-~~=��--- --'---
cumm-donm
use the return '`~~' '^~,`^' -__-- '_------ ------'----'--
kny, uv//^w» State Zip Code
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2� System Owner: &
Name ^ ~ ��- -----' ---'-------------------
Address(if different from mt------------'—'----------------''
Ck'�v�n ��------'---- '-' --------------- — �
__- ��^"= �
|
Telephone Number
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B. Pumping� Record �
'
1- Date nfPumping 2. Quantity Pumped�
3. Type of system: Cesspool(s) Septic Tank El Tight Tank El Grease Trap
El Other(describe)- --'------------�----'------_--_-'_'___- --
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? El Yes R No
5. Condition ofSysham�
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_ System . ...~~. By �
Vehicle License Number ���-------'
on,"vuuo Septic �
Company -~��� ---' --- —
7. Location where contents were disposed:
S MU _Bradford,_MaO1835______________
Signature nfHauler �---'----'-----' --,------'--' ----Da
SIgnutu,evfRaoeFving zicility ----- --' --'— '----- '--- -- ---
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