HomeMy WebLinkAboutSeptic Pumping Slip - 270 SOUTH BRADFORD STREET 6/16/2016 Commonwealth c
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System Pumping Record
Form 4
CEP has provided this form for use=by local Boards of Health. Other forms m&' 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 Locatio . LeigliFrcf of housed Left/Right rear of house, Leff/right side of house, Left/
Right side of bull ing, Left/Right front df building, Left/Right rear of building, Under deck
Address
City/rown State Zip Code
2. System Owner.
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Name ....
Address(if different from location)
City/Town State�� /� „ � 1p Code
Tele i-one Number
Pumping ecora__.._ �•.
6467 C, .
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 present? ❑ Yes ❑-lo If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of stem:
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`✓ - a
6: System Pumped By:
Neil,Batesbn F5821
Name Vehicle Uicense Number
_Bateson Enterprises Inc'
Company
7. Ma ere contents-were disposed:
S. Lowell Waste Water
71 W
Sign a Haule Date
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