HomeMy WebLinkAboutSeptic Pumping Slip - 140 LACONIA CIRCLE 1/11/2016 ` -
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Commonwealth Ma8,sachusetts
City/Town of N r f6 And
}ver
�����K� ���00�~�� ������ '
_���� Pumping� o^� " �
Form z%
DEP has provided this form for use by local Boards ol Health. Other forms may beused, but the
infnrmationmuetbeaubntantia||ytheeameanUhatprovdedhena. Beforeuaingthiofo ` oheok
with
local Board of Health to determine the form they use. The System Pumping Record must besubmi `~the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCIVIR15.351. `
A. Facility '..._....~~.,=""
Important:When ]AN 1
filling out forms 1. System
on�eonmpme� ' JU�NUFNDRTKAND0VZR
use only'the tab coo e
/ / �-- HEAUHDEpART�[N[
key� Address eyou, Address --= ----�----�'--------' -'� --------------
cursor'uonot
North~"' "''°""e' --�-----� --�-' --�� � - '-------- -- ---------
key. City/Town State Zip Code --'
2. System Owner �
Name « - ---- -- ---- -----------
Address Vfumerenfromloratiu�)—
------ - -' '-- ---'-----'------
Zh�ro�n _---------'- --' - ���''------------ - |
B~ Pu00�Di�� ��
Pumping Record �
- �
1. Date of Pumping __ ������- 2� Quantity Pumped: Gallons 3� Type ofsystem: F-1 Cesspool(s) Septic Tank E7 Tight Tank Fl Grease Trap
El Other(describe): ----'------_-'-�-____--____---------'
4. Effluent Tee Filter present? El 0m El No If yes, was it�ean-ad? D Yes F� No
6. Condition ofSystem:
- -'-^~^ ' ~^'red By �
�
--_-- -- '--_� -_____ �
vuo' ��uo-en oe wumb e- �
Stewart's Septic Service
Company �---'-- '-- -- �
7. Location where contents were disposed: �
_~_~`~ Pre-treatment Plan Bradford, Ma
---------
�gnam�nr��o�r ��--------' —'-----'--- -----
o�nameo/�eoewi:�g Y_ '-'-- - -�'-' ����e---- '---- - ------______
t5fwm �oc-03/06
System Pumping Record-Page I o