HomeMy WebLinkAbout- Septic Pumping Slip - 459 SALEM STREET 6/4/2019 wealth CM!
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System Pumplono Record
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.P has provid'edi form for use;by local cards,of-Health. - forme y a `Used, but the
Information-muse be su y e s .t s form,check w �� your
f 1 Board f Health t6 determine the forrhthey,use. TbeSystem Pumping,Record must be submitted to
the local Board of Health ether � l
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Left/19 0 Left/Right rear of
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Address
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city/Town State Zip Code
2. System Owner,
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Name
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Address if different from location
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Telephone umber
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Pumping Record
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11, Date of ,i Date ... 2. .. Pumped: ---------
3. Gallons system: E] cesspool(s) Tank Tight Tank
Otherrib
4. Effluent Tee Filter present? ale-o-s�Fo No If yes, was it cleaned? [9o--"Ws No
5. cCondifion of
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. Sptem Purnped By:
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Name Vehicle n umber
Bateson E��rlses Ina
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Company
disposed:
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Lowell Waste Water
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Hbul Date
OWTM.dooa, System Pumping Record