HomeMy WebLinkAboutSeptic Pumping Slip - 21 EASY STREET 5/22/2018 On It u EM
System Pumping,Record TOWN C
IMDOVER
a
®EP has provided this form'for use>by local Boards of Health. Other fauns may be'used,but the
information-must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the ford they use. The System Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. FactlIty, InforMation
1. System Location: LeI/ @ht fro t onfro ton f how es ) Left/Right rear of house, Left/right side of house, Left
Right side of building, Left ig frim offiuildidg, Left/dight rear of building, Under degk
Address �`�,�/� ��,,,;
L/t. k c"` L°
cwrown State Zip Code
2, System Owner:
' AJamei
Address(if different from location)
city/Town ' State � Zip Code ;
Telephone Number
.B. Pum: Ing Rpcord
pil
1. Cate of Pumping Quantity Pumped:
Date Gallons r.
r
3. Type-of system. CJ Cesspool(s) Septic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yes No if yes,was it cleaned? Yes No,
5. Condition of System:
te
6; System Pumped By:
Neil.Bateson ' F6821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
t S Lowell Waste Water
Sign a Paul Date
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