HomeMy WebLinkAbout- Septic Pumping Slip - 120 GRANVILLE LANE 5/7/2019 � o ,
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System Pumping Record wi(
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DEP has provided this form for usevby
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local Boards,of,Health. Other,formt may'be'used,but the
for tame as that provided here. Before it in
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this!form. check wl h your
.1 Board of Health to determine the ` ' wg Record must be submitted
the I rd'of Health or other approving
A. Facility InforMation
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. System n. Right front of house, Right�r � of-house, � �� a � us Left
jj Right side uji * h of,building,, Left rear f 1i' Under c
Address
Udyf rown state Zip Code
System Owner
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Name
Address(if different from location)
Cityfrown stater L4
Zip,Code
Telephony Number
B. Pumping Kecord.
1. Date iI
'Type-of y Cesspool( , k
�El Other(describe):
4. Effluent Tee fr r If yes, was,it cleaned? Yes No
5. Cond"Mon of System*
6. System Pumped
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Neil.
VehicleName 1:1 Number
Bateson Ehte[prises Ina
Company
",P11 re contents were disposea:
Lowell Waste Water
06/03 System Pumping