HomeMy WebLinkAbout- Septic Pumping Slip - 76 EVERGREEN DRIVE 6/4/2019 y
Commonwealth
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�DJr/Af(i�CE
1� �VED
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Uty/Town of
System Pumping Record
VV�11�4 01 y!' y �
Form 4 DEIr,`,,'ot,",,J'\' I"
DEP s provided'this form foru z y l� w� �. Other, � r used,but � �
information-must su �s l Il � same as that provided he; . Before using.this form.,6heck with your
10061 Board of Health to determine the for M' tihey use. TheSystem Pumping Recordmust be submitted to
the local Board of Health or other approving fi .,
A. Facil"Ity InforMation
I. System Location: Left/Right front of house, Left RII t �� hour , e side of house Leftl
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Right side of building, Left/Right fr6nt of ii r deck
Address
cityrrown State Zip Code
2 A y e W '.
Address i to
Telephoneciwrown Stater,
ZIP Code
u
Pumping Record
µM
1. Date of
ti
Pumping .
Gallons
UAS to
Type-of system Gesspool(s) lepf.Tank 0 TOM Tank
Other
(descrolbe):,
4. Effluent Tee Filter present? Yes 0 If y . , was it cleaned? [:J- Yes E] No
5. i
0
System Pumped By.
Nell.
Name Vehicle License Number
Bateson Ehtemrlses Ina
Company7. a
t
,. , r
Lowello content&were disposed:
Waste Water
p. f
jz
Mbffn
. , , / ping Record