HomeMy WebLinkAbout- Septic Pumping Slip - 329 REA STREET 6/24/2019 Ithl
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Commonwea
s
F1
City/Town of
System Pumping Record
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DEP has provided thi's ibrm for useoby local, 1 . Other r Putthe
"i formag'on-must be subst6rifially the tarne �"
as that provided here. Before usng Ahis for .,
Check with your
M
1 Board of Health to determine the form' they use.The!$ystemi Pumping Record m�ust be submitted tc)
the local Board'of Health or other approving
A Faciflity InforMation
'nn;t ':U1. RSyigshtet ms LocaUo e'�' <rq
o4f 'ou,s 'elfi
n
4
l i � ' boil i , r i , Left right side of house, Left,/
building,i r k
City/Town state ZIP Code!
� 2. System Owner.
61100^-A
Address if different from I b
Zip Code
Telephony Number
.B. Pumping Record,
., Oahe of Pumping Date 2. QuiinfityPumped:
E]I Type-of system,: E] Cesspool(s) E3--�epflc Tank Tight Tank
Other(describe)
4. Effluent Tee Filter present? Yes o If yes,, wasiftin
.
Nell. _OCA
6. Systern Pumped By:
N
Name Vehicle
Ulcense Number
Bateson Eh!eM,rise
M
Company
*,
were disposed.
Lowell r
RIO
sign Hain Date
WbrM4.
