HomeMy WebLinkAbout- Septic Pumping Slip - 5/7/2019 I
I
1
Commonwealth
( rare J-,
C11
fty/Town
J
19
• Jr
p�
, jay N
System Pumping Record
�(I,a�m I"�,N��
F'orm 4
]ad �,� �
DEP has provided thi's form for ,;by my
information-must be substinfl'ally the tame as that provided here. Before using.this form,check with your
local Boar lthdetermine
the local Boardr other approving .,
A. Facility
. I ht frontrear of-house, Left.I right side � Leftl
,Right side of building i ro of buildinrear cif building,
Address
U51 1673 0,?, C�\P�
CRYrr
owl State ZIP Code2. System Owner:
.
...
Address
Of differentlocation)
f
ciwown Stater Code _
TelephoneNumber
,,B. Pumping Record
PumpingI Date of
°
Gallons
3. Type-of system,., El Cesspool(s) eptlic Tank El Tight Tank
all
[j Otheir
I
(describe),
1
4. Effluent se Filter present? l Yes 0 if yes, was it cleaned? Ej Yes N
5. Condition of System:
,W
. System y.
,Nell.
Name Vehicle - 'Number
Bateson Ehte!Prisies Ina
Company
a .
Q. Sj?, Lowell Waste Water
Sign a Hilul Date
t6ibrm4.d=o 06/03 System PumpingRecord