HomeMy WebLinkAboutSeptic Pumping Slip - 185 BRIDGES LANE 12/28/2016 Commonwealth f chin �e a�,,,s �,u
City/Town of
tem Pumping
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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 game as that provided here. Before using.this fora,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted t
the local ward of Health or other approving authority.
® Facility, Infor lion
1. System Location: Left/Right front of house, Left/Right rear of house, Left/rri i
o , Le ft f
N Right side of building, Left/Right front of buildidg, Left/Right rear of building, Under
Address y
city/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town � State y�„u ^ alp ode
"telephone Number
!;
P"wiping l r
1. Date of Pumping Date 2. Quantity Pumped; Capons
. Type-of system'., Cesspool(s) eptic Tank Tight Tank
El Other(describe).
4. Effluent Tee Filter present? E] Yep -14o If yes, was it cleaned? [ Yes El No,
6. Condition of System' — ..•
6; System Pulped By:
Neil.Sates®n - E5821
Larne Vehicle Llcense Number
Sateson Ehterprises Inc,
Company
7. Locgfiqn where contents were disposed:
G .SQ Lowell Waste Water
Sign t e Haule Cate
t5fbrm .docm 06/03 system Dumping Record®Page 1 of 1
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