HomeMy WebLinkAbout- Septic Pumping Slip - 311 DALE STREET 5/7/2019 •Commonwealth
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Ale,
Uty/Town of
System Pumping Record �"A
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Form, 4 'cl �`' '
DEP has Provided this r 4 .,
Other forms maybe*Used,b'ut the
informag'on,must be subst6ntlally,thetame as that provided here. Before using.this form,check with you,,r
local Board of Health to determine the,form' they use.ThaSystem Pumping Record must be submitted to
the local Board of Healthr approving authority.
,A. Facifity Inform' aflon
I S ystem Lo ca,tion.- Left R Left]R' ht rear of.
tij`fit ig
w v19
house, Left Might si'de ofhouse, Left I t
Right 1 it � w i " ht rear ci�f . ,,, Under deck
Address
C wn
State Zip Code
2. System Owner,
,t
i
I
Address to i
UwTowri Late. Zip Code
m.
Telephone Num6er
R.,
PumpinoRecord,
LI 2
. Date of PumpingaGallons
3. 'Type-of system" Cesspool(s) E3;Septic Tank D Tight Tank
Other(describe):
4. Effluent Tee Filter Present? 0 Yes 3 No If yes, was 4t cleaned? Ej Yes E] No
Condition6.
x
V IV
System Pumped By::
�.
Nell.Bates7on F5821
Narne Vehicle License Number
a es E e rises Inc-
Company
7. Location whiffe to i
WaterLowell Waste
Sign
tlbA,oca,06/03 System Pumping Record Page