HomeMy WebLinkAboutSeptic Pumping Slip - 230 FOREST STREET 4/24/2018 Commonwealth of Masu
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DEF'has provided this fora for use by local Boards of Health. Other forms maybe used,but the
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information"must be substantially the me as that provided here. Before using.this form,check with your
local Board of Health to determine the forth they use. The;System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Factfity InforMation,
1. System Location: Lei ` ht torts of hiousp Left!Right rear of house, Left./right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear df building, Under deck
Address C
CIWTown state; Zip Code
2. System +Droner:
Name'
Address(if different from location)
City/Town - StateG�C �� .. r�r ? c+ode ;
"telephone Number
i
k
1. Date of Pumping pate 2. (quantity Pumped: Daltons
3. Type�of systemi: El cessspool($) eptic'Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yes o if yes, was it cleaned? ❑ Yes No,
' S. condition of System:
6. System Pumped By:
Feil.Bateson " F6821
Name Vehicle t icense Number
Bateson Enterprises Inc"
company
7.4signe
re conter+twere disposed:
G. Lowell Waste Water
Himle Cate
t5form4.dor.-06/08 System Pumping Record b Page 1 of 1