HomeMy WebLinkAbout- Septic Pumping Slip - 49 ORCHARD HILL ROAD 7/2/2019 X.
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� S tetn, Pump"n§.Record
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DEP has provided this form'for use;,by local'Boards -Health., Other formis, `' 'use ,,Out the
inform -must be substintiallythe sarne as that provided here. Before using s form,,check with your
I l l determine they , The X s m,Pumping Record must, b i e� t
the local Board of Healthr other approving u w�rity.1. System Location: Left/Right front offi u R" X ��
A,. Facll�ty InforMation
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rear of house, Left-/right Side of house Left I
Right side of building, Left/Right ,r6nt o WWI Left I Right rear df building, Under,
Address Cc
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01tyfrown stateCode
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Name), 1001
, System Owner. A
Addressdifferent from,location)
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Telephone Number X�
.B., Pumping Record,
. Date of Purnpl Date2. Qu6noty Pumped. X w
Gallons
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3. Type-of sy�te W: cesspool(s) &.1septic To, nk Tight Tank
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Other scj
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4. Effluent Tee Filter present? 0 Yep, a No If yes, was it cleaned? Yes No,
5. Condition of System,
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Nell.Betesbq
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Name
Vehicle Ulcense_ Number,
tenon rises Inc-
Company
7. L contenta were
G. Lowell Waste Water
Sign Haul Date,
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. 8 T System PumpingRecord R