HomeMy WebLinkAboutSeptic Pumping Slip - 178 BRIDGES LANE 12/28/2016 Ifs Z EI
QtK n of
Pumping.tem iIw w' �.aw e u•s�w��: (°i
Form 4
F
D P has provided this form*for use-by local Boards 6f Health. Other forms may be'used,but the
information must be substantially the same as that provided hare. Before using.this farm,Check with your
local Board of Health to determine the forr'ri they use, The System Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Facility Information
1. System Location: Left/Right front of douse, Left/Right rear of hous righ id�"&,f�hh ss , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under k
Address l ,
cityfrown Mate dip ode
2. System Owner:
Name*
Address(if different from location)
Cityfrown '
• staC
R "telephone Number
1
Pumping t r // (\
1. Date of Pumping 2. Qu ntl Pumped-
Date :.
� Gallons
. Type-of sy tem' El Cesspool(s) d_T nk 'Tight'Tank
El Other(describe):
4. Effluent Tee Filter present? Ye p []"Igo If yes, was it cleaned? ® Yes E] No,
6, Condition of System:
,
6. System Pumped Sy:
Nell.Sat ®n - F5821
Name Vehicle License Number
Sateson Enterprises Inc,
Company
i
7. Location ww re contents were disposed:
Lowell Waste Water
;ign MeHaule Date
Morrn4.doo-06/03 System Pumping Record Page I of 1