HomeMy WebLinkAboutSeptic Pumping Slip - 481 REA STREET 12/13/2016 j
Commonwealth of Mashu5
Cjt�/Town of
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' ' ra 1�A NOKa H APIUMER
D P has provided this form for use-by local Boards of Health. Other forms may be'used, buff the
information-must be substantially the tame as that provided here. Before using.this farm,check with your
local Board of Health to determine the form they use. The System Pumping Record must be subrnitte�d to
the local Board of Health or other approving authority.
A. Facfl Information
I. System Location; Left/Right front of house, Left fight r__of_.h�Left/right side pf house, Left/
Right side of building, Left/bight front of building, Left/Right rear of building, Under deck
Address � � -
Ctty/,rown Mate Zip Code
2. System Owner:
ti
Name`
Address(if different from location)
City/Town _ State r t zip Co
Telephone Number
B. Pumping Record
v A:� c
1. Date of Pumping � 2. Quantity Pumped:
Gate Gallons r
. Type•uf system: Cesspools) ptic eTank El Tight Tank
Other(describe):
4, Effluent Tee Filter present? Yep c_ if yes, was it cleaned? El Yes No,
' S. Condition cf Syste .: .
6. System Pumped 6y:
Nell.Bat on - F5821
Name Vehicle License Number
atescn Enterprises Inc-
Company
7. L® tionAHaule�nrher contents-were disposed:
Lowell Waste Water Sign a Cate
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