HomeMy WebLinkAboutSeptic Pumping Slip - 49 ORCHARD HILL ROAD 6/18/2016 Comm
On wealth
RECEIVED
City/Town of
S item Pumping.Record
YS
4 m
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a r Form 4 j VV�j OI �: IJ�C� II fl��P�l�l.��lR
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DEP 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
1. System Location: Left/Right front®!,YwseLeft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/ ig°�ffront of builds ; Left/Right rear of building, Under deck
Address
(' l r 1j t. A)... Andb u-�-(
Cityfrown state Zip Code
2. System Owner:
Name' A -kA
Address(if different from location)
citylrown State Zip Code ;
Telephone Number l
piing.,, �mcor
1. Date of Pumping 2 Quantity Pumped:
Date °
Gallons �?
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
Lowell Waste Water
\AlfOA
Sign a I hlaule Dates •tl� � � F
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