HomeMy WebLinkAbout- Septic Pumping Slip - 437 SALEM STREET 5/1/2019 "
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Cpty/Town of
S tem Pum
Record
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Ping,YS
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DEP has providedthis form'for usepy locall Boards 6f-Health. Other forma may 'Used,b9t the
ifr ="must be subst6rifiallyprovided here. Before,using.thI ,chec,k with y .
local:Board of Health to deter M* they rs .,TheSystern PumpingRecord must be submitted to
the local Health or other approving authority. & a of
1. System w.
A. Fac[14Y InforMation,
. Right
Left.I r1ght side of house, Left I
�UvRight side of building, Left Right&60 of,bui, in*g,, Left, R.191hit rear(if building,, Under deck
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Address
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MY/Town State ZipCod
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System Owner.
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Frees different from location)
Telephone hone r
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.B. Pqmping
Kecord
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1. Date of Pumping r �'n i :
M
Date Gallons
3. Type-olf sy�terW. El Gesspool(s) �epfic Tank, Tight Tank
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Other sr1
4. Effluent Tee Filter ? Y3' 0-'N_�o �lf yes, was it cleaned? [:1- Yes El No,
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,- System �,
Nell. F5821
. Name Vehicle UlcenseNumber
Bateson rises Ins".
Company 1
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G. Sr. Lowell Waste Water 1
Sig a Hhul
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Pumping r