HomeMy WebLinkAbout- Septic Pumping Slip - 83 LIBERTY STREET 6/24/2019 ���//F��l�Nfl�l�CEIVED
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determineSystem Pumping Record
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DEP has prolvided this form for use,by local Boards offlealth. Other formt;may,be'Used, but the
Information,must be substinfially the tame:as that provided here. Before using.ffils fori check with your
10c,61 Board of Health to Pumping
local Board of Healthr approving authority.,
A. Facility Informattion
System Location: ' �hod � � � r r �house,� � L� � i side l house� L� ft I.
Right side of building, Left R11 htfront of buIlding, Left I Right rear cif fl , Under deck
Address
city/Town State zip Cody
i
System Owner.
f
Name
I
Address(INIfferent from to
Cityfrn Stat wZip Code
-fe--tep"hone Number
f
B,. Pumping Record
M
PumpingI DateI of
Date 2. anffly Pumped, ye
system.3. Type-of
0, Cesspool(s) eptic Tank ED Tight Tank
E] Other(describe): ....
4. Effluent Te-- r present? El Yes - . ., -....: cl-:. .,. .. ElI-
6. System, PuImped By:
if Batesbn F6821
Nanne Vehicle s Number
Batesion 1
E!:��rlsei Ina
disposed.company
l
r
Lowell Waste Water
Haul Date
.docP 06/03 System Pumping Record