HomeMy WebLinkAboutSeptic Pumping Slip - 96 FARNUM STREET 12/28/2016 •Commonwealth of chi Z ,` 1V
u City/Town of .
q . a SOMem Pumping.Record
01 �,wt
Form 4 iiN.w:.MIH
D P has provided this for for use-by local Boards of Health. Other forms may be'used, but the
information•rust be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facifity. Information
9. System Location: Left/Right front of douse, Le igd .hoc o, Left./right side of house, Left/
Right side of building, Left/Right front of building, Leff/Right rear of building, Under deck
• ,address � � ,4 � -�''��" ��.. ��'1.,�- '• ('�`
City/rown � � t state Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town ' State Zip Cade
"telephone Number i
i
d_
® Pumpling Rpcord
1. gate of Pumping o�te 2. Quantity Pumped- gallons 4
. Type-of system'.* El Cesspool(s) eptic Tank 0 Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Yep o if yes, was it cleaned? E Yes 0 Plc►,
' S. Condition of System:
A/01 �y
6: System Pumped 6y:
Mali.Bateson 85621
Name Vehicle License Number
6ateson Este rises Inc•
Company
7. Location where contents-were disposed..
Lowell Waste Water
. , .(
4Sie
t5form4.doc-08/0 System pumping Record page 1 of 1