HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 15 SAW MILL ROAD 5/28/2024 Gor,t► onwealth Of I cassad _:
,, _jl 7' Cityfl oWn of NORTH ANDCVI R MASSAC USaT►'
S -err- Pumping Record
JEP has provided this form for use by or-al Boards of Health. The System PutnpKg Record must
be submitted to the locai Board of Hea! t"h or other approving authority. �O�Qi
V - - - --
1. F._ c. iifv Informa.tio ,X-1
Important: Q
When filling ou! 1. System Location �0�� e�K
forms on the o
cornputer use f 5 - n i 1/----_*"�
only the tab keyto move your n /
cursor-do noto
use the return
CityP own State Zip Code
key. Qi
2. .System Owner:. O�`y
---
Name
-- w�
" Address(if different from location)
CitytTown —— Ap State ��•` Zip Code
Telephone.Nurnber� -- - -
,01
B. Pumping Record -----
1. Date of Pumping r.�tP ?_ Quantity Pumped: [;a!icns
3. Type of system: ❑ cesspool(s) [_-t<eptic Tank ❑ Tight Tank.
❑ Other(describe): - ----------------_---- ------
4 Effluent Tee Filter present? ?_ ,�Yes ❑ No If yes,was it cleaned? Yes ❑ No
{ Condition of Svsten.:
S ys-Lell) _Pu_'iiped Dy: �
Name 'v.i fi c L�6rsc,c,,t uer
Company
7. Location where contents were disposed;
Y-
Si off aule;
r .2, rl"Ss g /!d;-(p.'water/approva! /tFtcrr-s htm#inspect
t5fcm4.dec 0&;0' System Pumping kecord Page i or I