HomeMy WebLinkAbout- Septic Pumping Slip - 180 MILL ROAD 5/15/2019 p wo v,
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Form 4
DEP has provided this form for usevby local Boards -Health. Other formit may,beused, but the
informaAFon,must be subst6nfially the same as that provided Before rng.this form,,check,with your
local Board of Health to determine the they use. The. stem'Purnping Record must be Submitted to
the local card Health or other approving authority.
An Facility Infor Mation
. System L front of house, Left I house, Left. right sI s Left
Right side building, Left Right fr6nt of buildifig, Left/Right rear cif building, Under deck
Address
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,CKY
/TownState dip Code
2 System Owner
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Address(INifferent froml fond
CilWiDwin state
Telephone Number
B. Pumping,
ftecord
11. Date of IL
Other,ype-lof system," 0 Cesspool(s) &--S�epflc Tank Tight Tank
(describe):
4. Elffluent Tee Filter present?. 0, Yes 1040 Wyes, was it cleaned? E]- Yes E] No
5. Conidifion,of System:
Nell.6. System Pumped By:
Batesbg F582"
Name Vehicle Utcen
Bateson Eq!qMrIses, Ina
Company
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LowellG,LL 4SO Waste Water
Sign a Himi Date
t , . oP 31 System Pumping Record a Fags I, of i