HomeMy WebLinkAboutSeptic Pumping Slip - 205 GRAY STREET 7/19/2018 mb1� �dh�u,
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City/Town of
t m . in " Record
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DEP has provided this form'for us&by local Boards®f Health. Other forms may be'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 submltte�d to
the local Board of Health or other approving authority.
A. Facility. Inf®rmi atlort
I. System L®cati ; L igh �pfhous �Leff/Rightrear of house, Left/right side of house, Left f
Right side of building, Left/Rigilding, Left/Right rear of building, Under deck.
Address -- l {
Cityfrown State Zip Code
2: System towner:
Name'
Address(if different from location)
CityJ"rown
Telephone Number r r
i
Pumping cor
9. bate of Pumping i7ate . (Iu'2nti[y Pumped:
Gallons
3. Type-of system: EJ Cesspools) eptic Tank C1 Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yep o if yes, was it cleaned? ❑ Yes No.
5. Condition of System: Q V\I
6: System Pumped By:
Nell.Bates'on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatio ere contents-were disposed:
Lap Lowell Waste Water
Sign a Wilul Cate F
tftrm4.doc•06/03 System Pumping Record•Page I of 1