HomeMy WebLinkAboutSeptic Pumping Slip - 91 JOHNNY CAKE STREET 7/19/2018 Commonwealth I ; D% "
City/Town of liffl � 2.01
Pumping.
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ICER has provided this form for usaaby local Boards 6f Health. Other forma 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 forth they use.The Systerin Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facflity InforMation
I. System Location: Lftc fight front�f h , Lei/Right rear of house, Left/right side of house, Left
Right side of building, Le int of buiidirig, Left/Right rear of building, Under deck
Address
t IV\
Cityrrown state Zip Corse
2. ,System Owner:
Name'
Address(if different from location)
Cilynown state ZI Code
`telephone Number
r
® Pumping Rgeord
1. ®ate of PumpingZ Quantity Pumped:
Tate Gailons_ `
3. Type-of system: Gesspool(s) 0-Septic Tank 'fight Tank
Other(describe):
4. Effluent Tee Filter present? Q Yes o If yes, was it cleaned? ® Yes ® No,
5. Condition of?y tem:
6. System Pumped By.,
Neil.BatesFon F6821
Name Vehicle License Number
Bateson Enterprises Incr
Company
7. Locab here contents were disposed:
Lowell Waste Water
`7 f
slgn a H ule Clete
t51orm4.doc^08/03 system pumping Record @ page 1 of 1.