HomeMy WebLinkAboutSeptic Pumping Slip - 145 FOREST STREET 5/22/2018 Commonwealth „;YEN
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DED has provided this form for use�by local Boards of Health. Other farms 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 forrin they use.The System Dumping Renard must be,submitted to
the local Board of Health or other approving authority.
A. adoty. Inform' sition
1. System Location: Left/Dight front of Mouse, Left " h�rear of hou `i Left/right side of house, Leff:
Might side of building, Left/Right front of building, Left/Wight ri�4 of building, Under deck
Address
mtyfrown State Zip Corse
2, System Owner: p
Name'
Address(if different from location)
Citylrown $tai— P ���" --��E � Zip Cade
P E
b Telephone Number
i
Pumping c
1. Date of Pumping crate 2. Quantity Pumped: Gallons
3. Type-of s stem:
y• El Cesspool(s) eptic Tank El `right Tank
Ej Other(describe):
4. Effluent Tee Filter present? D Yep o If yes, was it cleaned? ❑ Yes ® No,
5. Condition Qf System*
6: System Pumped By:
Neil.Batesoon F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Local re contents-were disposed:
G S: Lowell Waste Water
' F
Sign a Haul Cate
tftrrn4.doob 08l03 System Dumping Record d Page 1 of 1