HomeMy WebLinkAboutSeptic Pumping Slip - 492 SALEM STREET 7/2/2018 Commonwe.althcu
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Pumping. '
DEP has provided this forrri for use.by local Boards of Health. Other forms maybe'used,but the
Information-must be substantially the tame 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. FactlIty, Inform
t1
1. System Location: ej " ig front�of Mouse Lett/Right rear of house, Left/right side of house, Left,/
Right side of building, Left/Right from o ulldifig, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.'
Name
Address(if different from location)
CitylTawn Stat Z'
Telephone Number
Ile
Pumping
.. pc r
9. Date of Pumping2. Quantity Pumped: - --=-fi
Date Gallons
3. Type-of system: El Gesspool(s) 0-5`epbc Tank (l Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? ® Yes El No,
Condition of System:
6: System Pumped By:
Nell.Bateson • P5821
Glome Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lo do a contents-were disposed:
L S Lowell Waste Water
Sign a Hhule Date
t5farm4.doca 06/03 System Pumping Record•mage 1 of 1