HomeMy WebLinkAboutSeptic Pumping Slip - 20 ENGLISH CIRCLE 3/28/2016 Comm
on wealth
n C i yffown O
Pumping.YS
rd
Form 4
CEP has provided this form for use=by local Boards of Health. Other forms may be'used{ but the
information must be substantially the same as that 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.
A. Facility, Information
Right side of building, Left/Right front of building, Left/Right rear of b i ding, Un er thou , Left/
1. System Location: Left/Right front of Mouse, Left/Right rear of house
Address
Citylrown State Zip Code
2. System Owner:
Name
Address(if different from location)
citylrown State Zip Code
Telephone Number ti
j
r
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped:
Gallons
3. Type of system: ® Cesspool(s) ❑— eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? ...°W N
• p ❑ Yep ❑ o If yes, was it cleaned? ® Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Batesan Enterprises Inc
Company
7. Location., re contents-were disposed:
.L S. Lowell Waste Water
Sign a Haule w Cate
t5form4.doc>06/03 System pumping Record•Page 1 of 1