HomeMy WebLinkAbout- Septic Pumping Slip - 32 DEER MEADOW ROAD 10/31/2018 aCity/Town of
System Pi Along Record
HEALTH DEF-IMTIM011"
DEP has provided this form for use>by local Boards of Health. Other forms 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 forrh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility f r ti
1. System Location: Left/Right front of house e .�� Igh eft/right side of house, Left
Right side of building, Left I Right front of bul-a ig, Left IZ-N—�t rear of building, Under de+c€c
Address
Citylrown State Zip Code
2. System Owner �,/-t:,..�c✓�,�'"" �.
Flame'
Address(if different from location)
City/Town state � - ,_..�`�,r,���Zi�°�C)s
Telephone Plumber
Pumping Rec
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system: El Cesspool(s) eptic Tank ® Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes o if yes, was it cleaned? Yes No
5. Condition of System:
6. System Pumped By:
Neil.Bates ri F5821
Flame Vehicle License Plumber
Sateson Enterprises Ina
Company
?. Loca' n her contents,were disposed:
L S-Q Lowell Waste Water
Sign a Haul Cate
t5form4.doc,-06/03 System pumping Record a page 1 of 1