HomeMy WebLinkAbout- Septic Pumping Slip - 781 WINTER STREET 6/24/2019 I
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Commonwealth
RECEIVED
city/wrown ot
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System
Record
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Form 4
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,DEP has provided this form for use,,by local Boards of,Health. Other form may,beused,but the
Information-must be ll r
the,local Board of Health or other approving authority.
loc,61 Board ofHealth 6 determine the for M' they use. The.System Pumping, Record must,be submitteo to
A, Facility InforMation
1. System Location: Left(, it�opf_lhl�ou�s4�,,, Left R! ht rear of§a� houso, Left right side of house, Left I tf ro 9
Right
i ' , Right building, Under deck
Address
IGN,
cityrrown State zip Code
Owner.System
Name'
Address(if diffeirentfrom l
cityfrown ,y Zip
-fe—lep,hone Number
,B, Pumpling Record
1, Date of rDate Gallons
3. Type W Ej Cesspool(s) B--,S�eptic Tank Tight Tank
Other(describe):
i
_ 1,
Effluent e Filter eI' ElYes, 3"�r� I yes, was cleaned?
N
El Yes El No
S. Condition of,System:
,w
System Pumped By,.,
Neil.Batesbg F6821
Narne Vehicle License Numbeir
t
Bateson Ehterprises Inc.
-
Company
were disposed.,
ll Waste Water
S "bul
t51brm4.doc&06/03 System Pumpingr ,