HomeMy WebLinkAbout- Septic Pumping Slip - 380 BOXFORD STREET 5/1/2019 Commoweialth
ERG
l� (/1////IJlllek U y�! y l/I�i`E
'In
f��l�ir�rt�r�Irk �/,r,
Uty/Town o.
f �
e a P
f
W
s•� System
��� iy H A
a E m
Foun 4
"".
DEP has Provided this form for use4by local Boards of"Health. Other formt;may"beused,but the
16
information,must be substintially the tame as that provided
� Before l , k with
r determine m use. ing Record must be submitted
the local rd of Health or other approving
,A,. Falclifty InforMation
,I. System Location: M .
Right side of " Left/Right building, lit r it , rear cif
uil , U k
Addres
own, State Zip Gode
.. System Owner.
Name'
"
Address ' rw l fond
i w Cody
Telephone
B. Pum, ping Record
'. Date of Pumping ----------
Gans
3. Type-of systeml: Cesspool(s)i eptic Vc ".
Other(describe):
4. Effluent Tee Filter present? Yes Ej'-�No If Yes, was it cleaned? [1- 'Yes Ej No,
Condiflon of System:
Systemy
Nell.
Name Vehicle u
",tejrses Inc-
company
7. Lo here contents-were disposed.
ell Waste Water
re
Hilul Date
/ stem PumpingRecord