HomeMy WebLinkAbout- Septic Pumping Slip - 116 SHERWOOD DRIVE 6/4/2019 1,
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4 a � System Pumping
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P has provided this fbrm for usepby local Boards of-,Health. Other
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information-must be snlly the tame as that provided here. Before usIng.this form,cheek with your
loc,61 Board ofHealthr they use. Th ping Record must be submitted,
the,local BDard of Health or other approving authority.
X Facility Infor Matillon
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Systemfight front of house, Left ! r house, Leff/right ales of house� Left,/
Right side of building, Left', " htftnt of building, Left Right rear building, Under deck
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Cww state alp Code
2. System Owner,
Name-
Address:(if
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differenit from wcaflora)
Cityrrown mate, Zj de
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Telephone Number
B. Pumping Record
1, Date of Pumping Date 2. Quii,nfity Pumped,: Gallons
3. Type-of system: Cesspool(s) nk sight Tank
E] Other(descrolbe)I:
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4. Effluent
Tee Filter r Yes If Yes, was it cleaned? Yes El
. Ci stem:
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Sy By
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Nell.
Name Vehicle License Number
Company
'on-where'on-where contents.were disposed.
11 Waste Water
Haul
Slg4fi` Date
t 3 System Pumping Record Page 101