HomeMy WebLinkAboutSeptic Pumping Slip - 26 STONECLEAVE ROAD 7/23/2018 n ( u MEIVD
CHY/Town of .
23 01
SY.4tem Pumping.RecordOM OF NORi ui�i� � i
®EP has provided this forrri for use-by local Boards®f Health. Other forma 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 form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
. WInfor miationr
I. System Location: Left/Right front of house, Lett/ i h jjjr of haus eft/right side of house, Left
Right side of building, Left/Right 66nt of building, Left%Right rear of buildin Onder dept
f
Address
oce
Dity/1'own state Zip Code
2. System Owner:
' Mama.
Address(if different from location)
City/Town ' Stater Code
�,..
'telephone Number
r
1nr
1. bate of Pumping date 2. Quantity Pumped: Gallons
I Type-of system: E] Cesspool(s) eptic Tank [] Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes ® o if yes,was it cleaned? E Yes [I No
5. Condition of Systern: ,
6: System Pumped By:
Neil.Meson ' P5821
Name Vehicle License Dumber
Bateson Enterprises Inc'
Company
7. Locati re contents-were disposed:
�L S Lowell Waste Water t
_ 2
sign HIIUINU Date
t5form4.doo-06103 System Pumping Record Page 1 of 1