HomeMy WebLinkAbout- Septic Pumping Slip - 1510 SALEM STREET 6/4/2019 I �N
CommonweWth
���6 7� II!/((!(tlN� I n�«�rGi�ll II✓a��ue�;
�IRI"
Uty/Town of
[,IAY
System
4 ,
a Pumplong
"rOMiV p ppON
Form 41 DEJ
here.DEP has provided this form for usebyi local Boards of Health.i Other formt;may,be'used,but, tihe
Information,must be substinflally the same as that provided
Before using.thisyour
1=61 Board of Health to determineiRecord must be submitted to
the local localBoard of Health
A. Facility, InforMation
11, System Location.- Left/Right front of hous r .� 'w right side
t lea.,
Right side of I " of bui difig,, Left/Right rear dif building, Under deck
Address
GItYf r0VVn, State Zip Gore
. Systemc,
m
Addressdifferent from location)
City/Town state ZIP ode
Telephone Number
R Pumping Record
Date Gallons
Other3. Type-of system: Cesspool(s) [D,89'p"fiti Tank Tight Tank,
E] (describe):-
4. present? y leaned? Yes No
Condition5. l
y
System6.
m
Nell.Bates7on F5821
Name Vede License Number
Meson hi rises Ina
Cy
7. Lo contenterwere disposed.
Low,ell Waste Water
Date
m . c 08/031 System ping Record page 1.