HomeMy WebLinkAboutSeptic Pumping Slip - 165 VEST WAY 6/5/2017 too
Commonwealth of
City/Town of
System i
DEP has provided this form for use-by local Boards 'of Health. Other forms maybe'used, but the
information must be substantially the same as that provided here. Before�Ising.this faun,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 . Inf retro t 'n
I. System Location: Left/Flight front of Rause, Left/Right rear of house, Left/right side of house, Left/
s Right side of building, Left/Right front of building, Left/dight rear of building, Under deck
UC
,. ..�_
ify/rawern State dip Cane
2. System Owner: ( �
Marne'
Address(if different from location)
cityfrowvn State- k a de
Telephone Number
i
-------------
B. Pumping ftecord
i,
I. Date of Dumping Date ;:2. Qugan" -bumped: rattans i.
. "Type-of system*. Cesspool(s) eptle Tank D Tight Tank
El Other(describe):
4. Effluent Tee Filter present.? Yep o If yes, was it cleaned? Yes No,
' S. Condition of System: r
6: System Pumped By:
(Veil,Bates-on F5821
Larne Vehicle License Number
Bateson Este rises Inc'
Company
7. Lo "TF ore contents were disposed:
L Lowell Waste Water
Sign a Houle Date
t5fbrm4.docm 08/03 system Pumping Record Fuge 9 of 1