HomeMy WebLinkAboutSeptic Pumping Slip - 183 FOREST STREET 1/19/2016 �
C� Commonwealth nf Massachusetts
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City/Town r`f
System Pumping |
Form 4
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DEP has provided this form for use by local Boards of Health, Other forms may be used, but the
information m's1beauba�/nUed�the same as that pnzv�edhere. Before using th�h�m. check wbhyour
local Board of Health bo determine the form they use. The System Pumping Record must beeubm8�Vbo �
the local Board of Health or other approving authority within 14 days from the pumping dote in
accordance with 31OCKAR15.351.
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A. Facility Information
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only the tab key Address
to move your ��`�� _____ ____ __, _ _
cursor uunm �-- l�T���-- 3m� zip Code
use the return `
='. 2� System Owner: �
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B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Gallons
3. Type of system: F-1 Cesspool(s) ZYSeptic Tank 0 Tight Tank El Grease Trap
E] Other(describe): ----' -- ---- - ----- -- - ------ ----- -- ----'— -
4. Effluent Tee Filter present? 0 YesmAo If yes, was bcleaned? E] Yes 0
5. Condition of System: ~^ !
(l ' |
'D mber
Name
-- 1
T. Location where contents were disposed: Bradford,
ad a 01 83 5
Signature of jre?MF' Date
mmmw.o"o 03/06 System Pumping Record-Page I of 1