HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 JOHNNY CAKE STREET 7/16/2019 «
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DEP
has provided this form for use4by local Boards 6f,Heal'th.,Other form, t,may'be'used,b'ut the
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information-must be substinfially�the that provided here. Before,using. � �s check with your
locil Board ofHealth,t6 determine the forrh they use.TheSystern PumpIng Record must be submitted to
the local Board of Health or other approving
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A. FacIRY
InforMation
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1. System Location: Left Right fro�t of
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ouse,, Left,/Right rear of.house', I SO eft I
Right si� building, Left Mg6t fr6nt of buioldlhg, eft i uit
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Address
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C:j,lyfrown State, Zip Cody
. System Owner,
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Name' # it
Address "different from location)
Zip Code
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Telephone umber
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�«�yy Record
Pumping
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�4 m
Gallons
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0 Other(descHlbe):
4. r n Y Yes, was it cleaned? Yes No,
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S. Condiffion of
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System
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Name
Vehicle i umber
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Company
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content&were disposed.
m� G;M Lowell Waste Water
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