HomeMy WebLinkAboutSeptic Pumping Slip - 116 SHERWOOD DRIVE 5/22/2018 On ' I u Eu
• i .. n of
nrd MAY , 018
NATME r
DEP has provided this form for use-by local Boards bfHealth. Other forms may be'used,but the
information,must be substantially the Same as that provided here. Before using.this forret,check with your
local Board of Health to determine the form they use.The.System pumping Record must be submitted to
the local Board of Health or other approving authority.
A. FacilityInform' ation
1. System Location: Le /Right front pf hous d9a.
ig rear9fhour. , Leff/right side of house, LeftRight side of building, Left/Right front of bu`i i� Left/Rig rear of building, Under deck
Address
Citylrown t state Zip Castle
2'. System Owner
Name
Address(if different from location)
Cityi"rovun i Cade ;
E Telephone Number �� . ,`'t
J
1
. Pumping Rqcord �-
1. Date of Pumping Date 2. Quantity Pumped: Gauons��^"�.��
3. Type-of system: Cesspool(s) eptic Tank Q Tight Tank r
❑ Other(describe):
4. Effluent Tee Filter present? El Yes o if yes, was it cleaned? ® Yes ❑ No,
5. Cond'tion of System:
6: System Pumped By:
Nell.6atesbn F5821
Name Vehicle License Plumber
Bateson Ehter_prises Ina
Company
7. Lo ti re Contents,were disposed:
.L S: Lowell Waste Water
7
F
Sign a Haul e Date
t5formCdoca 06/03 System Pumping Record-Page I of I