HomeMy WebLinkAboutSeptic Pumping Slip - 72 STERLING LANE 12/8/2015 '
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Commonwealth nfMa,-� achU
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City/Town[�V��� `,/ North/ , �yl^�over
System Pumping Record
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Form 4
DEP has provided this form for use by local Boards of Health, Other forms may beuaed butthe
infonnahnnmust beaubatanUaUy the same aadhatprovdedhere. Beforeusingthis---~''^ oheokwbhyour
|oma| BoardofHmo|thtodotenninothefonntheyuaa. Th*SyotemPumpingReoord '^~~^ba submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in |
accordance vvith310C�NR16.351. u ~~ !
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A. Facility Information �
important:When
filling out forms 1. System Location:
un the computer,
use only the tab
key m move your Address -~�~-`�~=-------- -'-----'--- ----'----
cursor do not
North~'~' ~"'°° ----- ------- ----------'--- -
^», ``"'~~' S�� �-
� ��Code
2. m Sv�ba
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Name - ------- ---'-------'-
«��m �uiffe_remfror� vt------------- --- |
-- ` |
Ckyn�wn �-------'--- -- -----'----------- -
B. Pumping Record
'. Date of Pumping -------'--- �� Quantity Pumped: - -- --- �
--- sa/�na �
3. Type ofsystem: Fl Cesspool(s) Ueeptic Tank Fl Tight Tank Grease Trap �
LJ Other(describe): ----'----------- -7--_-___-__----' ......
--_--_ -_
4, Effluent Tee Filter present? n Yes ' /f yes, was itcleaned? [l Yes
5. Condition of System:
b. System Pumped By: |
mamu �---------- --'-------------------------__-___ �
Vehicle License -----
Stewart'r Septic ��
Company �--------' -- '- �
7. Location where contents were disposed: �
8bavvory P Mill Bradford, MaO1835______________
oignameofyauu� �---'----'-----' ----'---'--' ------
mgnatum c n p
of�eomvng�a � ----- -'- '--' ' ----' ---- -- ---
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System Pumping Record`page 1 of