HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 208 OLD CART WAY 1/2/2025 r�
-' 'mK�7� �
-..^����`
[`�)����[}n������|fh []f K��]ss��chus��ffs _ 'w��ker
/�'f /T f ��� -
`�|�V/ ' [)VV� {)/ '~
------- ~u��
S�s*��� ���[���^�� ������F�
~ Pumping Record
`~
Form 4 «'
DEP has provided this form for use by krua| 8oauja of Health. Other forms may be used, but the
information must be substantially the same as that provided here, Before using lhiy for ` check ck with your
local Board Df Health to determine the form they use, The System Pumping Record must besubm|tteU hr
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CK4R 15351 -
HOUSE: front back rear left
A. Facility Information BUILDING: front bock side rear left ,ight
Important:When DECK: under
filling out forms 1, SystemLooation�
nn the-computer,
use only the tab
key to move your Address �
cursor'ou not
use the re �A
return
key, °"'''~~" Zip Code
10 116Q 2� SyStem Dwne[
0 V�
Q21!Q
K0A
City(Town tale Zip Code
B. Pumping Record
1. Date of Pumping L' Z ------- 2. Quantity Pumped,
Gallons
3, Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
Fl Other (describe):
4. Effluent Tee Filter present Yea No M yes, was itcleaned? Yes 7 No
5. Observed oo ndiUo of t d '
S, System Pumped By.
DaveT|ne
Number------z---
ea�eson Enterprises, I
Cornpany
7, ion where contents were disposed-,
�ignature of Date
-�-15-nature f R�ceivl'n r attach facility receipt) Date
{Sfom4doo' 11/12 System Pumping Record 'Page 1 of
`