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Health or other a rovin authority.„ �� � �
p loan for use by local Boards of Health. a st { • .u ,pfragee rd must
be submitted to the local Board of pp g
A; Facility Information
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only the tab key Address C .0 to move your:; ”•?,� f c�c...�
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use the rem'l CltyiTown State
Zip Code
key owner,
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N. Name
Address(If different,from location) ---
cltyfrown• State
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Telephone
• ' p Number �����
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r. umping cats 2, Quantity Pumped:
Gallons
. .TYpe Qf s stem
y ❑ ':; Cesspool(s) —teptIc flank ❑ Tight Tank
❑ Other(describe). _
Effluent Tee Filter resent? 7 Yes ,�, 'ry
. p , • U'r�o If yes, was It cleaned? F] Yes ❑ No
`, ;' , 91,0 Syst
1
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�Vehlole Ucen$e Number
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Date
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System Pumping Record Page 1 of t