HomeMy WebLinkAboutSeptic Pumping Slip - 124 TUCKER FARM ROAD 1/11/2016 - �
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System Pumping� �����rd '
Form 4
DEP has provided this form for use by local Boards of Health.-D'therfonnamaybeuued- butt
he infonnationmuatbaaubstanbaUyth*eameasthotpnovidedare 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 authohtyvithin --ysfrom the pumping date in
accordance with 31OCKR15.351.
A. Facility Information
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m*. City/Town _State_
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Zip Code
Z System Owner: � &
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mumo ---- - ---- --'-----------'-------'-----------_____-_-
Addmao(ifdiffsremonm|omulom—
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citywn �---------'---- '- ---------------- -
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Telephone Number
B. Pumping Record
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1. Date of Pumping � e �- � 2. Quantity Pumped: -----
Gallons
3. Type of system: M Cesspool(s) Septic Tank n Tight Tank El Grease Trap �
U Other(describe).- ��---_�____ ____ _
4. Effluent Tee Filter present? Yes No |f yes, was itcl*eaned? Fl 0m [:1 No
5. Condition ofSystem:
6. System Pumped By: �
weme �----------------------- -'-------------------_____-_-_-__
voo |e ��noewumuo, ----- �
S�mmryoSe ti Service m u �
Znmpony �-----' --- --
7. Location where contents were disposed:
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.~~=°`" .Pre-treatment Plant, rd Ma 01835
mgnoture of xaui.r ----------- --------'-- ----
o�namreofRone�ngraoNv --- -' ---- -'------ ----'- ---
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System Pumping Record^Page 1 of