HomeMy WebLinkAboutSeptic Pumping Slip - 93 ROCKY BROOK ROAD 6/6/2018 Commonwelalthof hu
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®BP has provided this form for use-by local Boards of Health. Other forms 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 forrh they use.The,System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Fad4ty. I f ti
1. System LocattoIg ron of house, Left/Right rear of house, Left/right side of house, Left
Right side of bu , Left/ iuildlrig, Left/Right rear of building, Under deck
Address
CityPrown State Zip Code
2'. System Owner:
Name'
Address(if different from location)
City/Town ' State Z' Code
Telephone Number >
Pumping r !`
9. ®ate of PumpingData 2. Qu6ntity Pumped: Gallons
3. Type,of systerw. Cesspool(s) Septic Tank 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yep o If yes,was it cleaned? E Yes ❑ No,
' 6. Condition of System:
6. System Pumped By:
Neil.Bateson F6821
Name 'Vehicle License Number
_Bateson Erater�rlses Inc•
Company
?. Lo ere contents-were disposed:
t�S Lowell Waste Water
Yl
Sign a Haul Cate F
t5forW.doo-06/03 System Pumping Record a Page 1 of 1