HomeMy WebLinkAboutSeptic Pumping Slip - 140 CHRISTIAN WAY 7/30/2018 vygl��
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"Syitem Pumping,Record
Form 4 tjEA L. :iD .�ARI EN
CEP has provided this foifri for use-by local Boards of 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 t
local Board of Health to determine the forrh they use. The System Pumping Record must be submihe~d to
the local Board of Health or other approving authority.
A. r
Faclift, Informiation
1. System Location: Left/Right front of douse, Left/ iear o e, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Ci drown S Zip Code
2. System Owner: -------
' Name'
Address Of different from location)
cityf own Sta a Zip Code
Telephone number
Pumpling Rpeord .
1. bate of Pumpingnate 2. Quantity Pumped: Gallons r
3. Type•of .systerin: El Cesspool(s) ptic Tank Ej Tight Tank
[l Other(describe):
4. Effluent Tee Filter present? ® Yc o If yes, was it cleaned? ® Yes ® No. j
6. Condition of stern:
C' ,� � f
6: System Pumped By.
Neil.Satesort F5821
Name Vehicle t tcense Number
Bateson Enterprises Ina
Company
7. Locatio re contentsrwere disposed:
Lowell Waste Water
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Morm4.dock 06/03 System Pumping Record a Mage 1 of 9