HomeMy WebLinkAbout- Septic Pumping Slip - 50 JOHNNY CAKE STREET 6/13/2019 ��o,
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Gommonweialth of Massachulseffs
City/Town of
Systefn
Pumping
Record
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Form, 4,
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DEP has p.rovided this form for1 y local Boafds of Health.Other formt; y
,beused, but the
Boardnformeflon-must be substinflally the tame as that provided here. Before using.this form.,c'heck with,your
local of r i for, they use.'Tbe
l l Board of Healthr other approving
A,. Facility Infor M" ation
1. System Location: Left Right front of houis W Ighl
eft- right side of house Left/
Right fof�
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Address
Ofty/Town State ZIP Gode
., System Owner:
Name
Address(if different from location)
City/Town,
x�x
Telephone Number
R, Pumping K-ecord
Pumping1, Date of ate
' 2. Qu6nfity Pumped: Gallons
3. Type-of9--septileTank D Tight Tank
Other(describe):
4. Effluent Tee FlIter present? 9' ,Ies E01 No If yes,was it,cleaned? N
5. i � ► *
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FrIC
. System Pumped By.
Neff Batesbn f5821
Narne Vehicle License Number
Bateson r Inc-
Company
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wheren were w 1
l Waste Water
WAD #4
Sign e, Hilul Date
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. b 06/03 System Purnpina Record