HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 50 ROCKY BROOK ROAD 6/16/2025 Town
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Form 4
OEP has provided (h/o /o/m for use by local 8oeoju of Health, Other hz/rna may Ue used, cut the
information couo1 be substantially the same ax (ha( provided here. Before using |hiy k`rm, checkwkk your
local Board of Health to determine the (nrm \Uey use The 3yu(enn Pumping Record must besobm\tteU <o
the local Board of Health or other approving auNo/i(ywithin 14 days from the pumping date in
accordance with 318Ck4R 15,351
HOUSE: front back ft
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A. Facility Information 8U|LD|wG� front back - rear \ef-I
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1 Date ofPumping �4y�~�----- 2 Quantity
Gallons
3 Component: LJ Cesspool(s) Septic Tank Tight Tank Grease Trap
Fl Other (describe), '
4. Effluent Tee Filter present? L] Yea No if yes, was it o)oeneg? n Yea [] wo
5, Observed condition of component pumped.
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Name vemo/e. Lic^,~omvmu
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Company
7, LocuUonvvhere conieni5 were diopooc0:
Date
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