Loading...
HomeMy WebLinkAboutSeptic Pumping Slip - 575 TURNPIKE STREET 12/8/2006 19/19/2006 16,-12 y7868Q8476 HEALTH PAGE Q2/92 . �'iG1I'1"ii'nt�i'iWe+�iti'1 ® (�a$ �Cil $etfi$ ' ity1 "c�wi� JAN G 2007 SYStOM Pumpl g P,ecorl� TOwVNopt4ORTt-tANDOvt=R art 4 NEA�rtii�rz i AaI.�Vr" PaP hits provtcted this form for use by local wards of Health. The System Pumping Record mast be submitted to the local Board of Health or other approving Authority, Ax Facility Information'M Important: When filling out 1, System Location: �--- fOrMa Oh the computer,use .. .�.. J . only the tab key d Ere m to move or- your __ !C Cvr3or-do not CI 1T'ourti use the return SS atWO key, Zip Coda 2. System Owner: j/ Noma Address{If tf�fe I o.t - -§1"a t e a �p ode ----- Telephone umber 13- PUMPIng Record 1, date of Pumping Data v--� a, Quantity Pumped: Gallons 3, Type of system: Q Cgsspooi(s) © Septic Tan ❑ fight Tank Other(describe): 4. Effltaent`Tee Filter-present? ❑ Yes No If yes,was It cle4*ned? Yes ❑ No 5, Condition of System; 6. System umped fay: �� . .� Namd ROOTER-MAN Vetllcle Lfoensa Nurt $r 12 EAST DRACUT ROAD 0►hpeny METHUEN,MA 01844 7. Location wijsre contents wero disposed: l� J� Slgnatur of H for -- + U U http:Uwww.mass.gov/dep/we ter/approvals/k&fOrms.htM#Inspect Date t6formCdoc-06103 system Pump)ng Record Page 1 of 1