HomeMy WebLinkAbout- Septic Pumping Slip - 2109 TURNPIKE STREET 5/29/2019 r
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Must be substantlally the same as tlh may ble used,but this
ermine the form�t � use
at provided here,the tocial 180ard of He,alth or other improving
before using this form, check wlth your
1000,1 1301ardof'Healthto .T1108yatem Pumping
Record must be submitted to
8=0rdance with3 CI 5,3authorit from the PUMpIng date in
A. Facility Inform,
an
IOrt "When
Ming ow&m,�3 I. System Location
on the computer,
ut ,
use only the tab
key to move your
Address
cursor-do not
Use the return
City/Town
State
w ZIP Code
System Owner
t
Name La
�'
T063(if different from w1
Cl /T ,r
State
ZIP Code
B. Pu
11
Date Of Pumping 15
Date 2. QuantityPumped:
3, Component,* Cesspool($) SePtlic Tank
11 on
0 Tight Tank Grease Trap
Other(describe):
i
1
Effluent Tee Filter present? El, Yes
6, Observed condition Of component pumped: If Yes, was It cleaned? Yes No
0 No
J
�t
System Pumped
Name
` g I& Tdu' � � ���� Number
5 1 Hallberg Park
cow or s
t Location where contents
µ
MCI-
Date
Si n tur • 0010h lift or 1P Ity revel t
) Date
sYatern PulvingRecord Page 1 of 1