HomeMy WebLinkAboutSeptic Pumping Slip - 224 HAY MEADOW ROAD 2/20/2018 Commonwealth of Mashu
RECEIM
Citk/Town ofIT(
Syitem Pumping.Record
Fonn 4 TOWNNORTH ANDMIR
HEALTH DEPARTMENT
DEP has provided this form for use�by local Boards of'Health.Other forms may be'used, but the
information-must be substantially the game as that provided here. Before using.this form,check with your
coral 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. Facility I for ti
1. System Location: Loft/Right front of Hous ig r�houa e, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address rr
-alt-y—ifown State Zip Gone
2. System Owner:
Name
Address(if different from location)
City/Town State's G �—ili- 15 Gads
Telephone Number
1
_-gg n cp �r
1. Cate of Pumping ate 2. Quantity Pumped: Gallons �
3. Type-of s stem:
Yp Y. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes o if yes, was it cleaned? ® Yes ❑ No,
5. Condition of,System:
6. System Pumped By:
Nell.Satesan F6821
Name Vehicle License Number
Bateson Enterprises Incr
Company
?. Lo bon hire contentewere disposed:
P� S Lowell Waste Water
. f
Sign a Hauls tate
ftrma.doc-06/03 System Pumping Record.Page 1 of 1