HomeMy WebLinkAboutSeptic Pumping Slip - 80 CHRISTIAN WAY 5/1/2017 Commonwealth
Cit�/Town of
VE
SyMem QRecord
.117
®EP has provided this form' 411
for use-by local Boards Health. 0410rMt �i L fed, but the
information'must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the farm they use.The;System pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facfl�ty. Information
I. Right side of building, Left/Right frbnt of build , .... 1tt i osQ Left-/right side of haus , Left/
System 9 r Leftt
s building, Under deck
Address
l r
ryry
"`".'x
CRY/,rown state-
2.
tate „ dip Castle
20 System Owner: �-
memo,
Address(if different from,location)
City[Town _ Ctate," ' Code
s Telephone Number
® Pumping Rpcord
1. fate of pumping date Z Quantity pumped:
Gallons
. Type-of system: El Cesspool(s) Septlo Tank D Tight Tank
•
Ll
Other(describe):
1
1
4. Effluent Tee Filter present? Yep u If yes, was it cleaned? El Yes [I No,
' 6. Condition of System:
•
6: System Pumped By:
Nell.Set 7on - E5821
Dame Vehicle License Number
Bateson Erste rises Ina
Company
7. Lo do t# re contents-were disposed:
Ine
WHIaule '
Lowell Waste Water
Date ff
t5ferm4.docb 06/03 System pumping Record®page I of I