HomeMy WebLinkAboutSeptic Pumping Slip - 22 BANNAN DRIVE 12/28/2016 :.
Commonwealth � EIV
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®EP has provided this fora for use-by local Boards of Health. Other forms may be'used, but the
information-must be substantially the same 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 submitted tc)
the local Board of Health or other approving authority.
A. Facility, Information
1. stern Location: Left/Right front of house, Left/ tear of h U e; Left-/right side of house Left/
System g 9�... _ g
Right side of building, Left/Right front of building, Left/Ffigh rear df building, Under deck
Address D
City/Town _ state Zip Corte
2. System Owner:
Name'
Address(if different from location)
Citylrown ' Mate Zip code
relephone camber
i
h
Pumping J ]{ f
1. Date of Pumping pate . Quantity pumped: Gallons �
3. 'Type•of system`: El Cesspool(s) fade Tank (l Tight Tank Y
El Other(describe):
4. Effluent Tee Filter present? Yep a if yes, was it cleaned? E] Yes. Na
6. Condition of System,
6. System Pumped By:
Nell.Sat on F'5821
Name Vehicle License Number
Bate on Enterprises Inc-
Company
7. isigne ` ere contents vti►ere disposed:
Lowell Waste Water
Houle Clat®
t5form4.doc®06/03 System Pumping Record Page 1 of 1