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HomeMy WebLinkAboutSeptic Pumping Slip - 5 CHRISTIAN WAY 1/22/2018 -forms may be used, plrP has this fprr for use by tacsl hoards of Health.Otrt Befo a using this form.cleric with your Provided: as ttfat provided herebe ,nforrnattcrt must be sub5ts ntially the sarrae they use_The System Pumping Record imudal>a in submitted to local Boarq of ealth to. o dor Other por+�ui authority wltlljn 4 days frgtn the pumping f he local pard of H1e4 th 15-351, accordance with'310 C I A. Facility inf rMatiOn impotent: ,When Ailing oul 1. SystemLocation- on the — ,omputer,use only tale tab key 0.ddreSs A- _ � Zcp Code to r+'so've yCtur ��._ � ��lJ � -. a''131� wj�r..00 not Gr ,.... use 1he•1elurn t1yuT7 kev 2. Systm,owner: #4 _ iC —C-51 War*. _. "+ + Addtx f,rr�rfferent fr6rn tocafion} Z?p�Code C1fyfTowm Telsphaie I+tumber B. Pumping Ord ! 2 Quantity Purnped Gannrss 1 mate of PurnPing rat [:1 Grease Trap 3. Type of systerCesspool(s) Septic Tank ❑ Tight Tanic rt: ❑ ❑ Other(describe)' - - 4. Effluent Tee Filter present? ❑ yes( ,No It yes, was it cleaned? ❑ Yes ❑ Nn 5. Condition of System_ 6. system Pureed By. 0 7 M�._ L cense Numbef — - Nor" Company .. . 7. Location where contents were disposed' NOM Andown MA ©rate I f Si9Rarure of Receiving Facility System pumpinq ReCord Page 1 of 1 15form4 doc•03106