HomeMy WebLinkAboutSeptic Pumping Slip - 317 RALEIGH TAVERN LANE 12/9/2014 Commonwealth
p W City/Town
t System Pumping Record � a
Form
CEP has provided this form for use:by local Boards of Health.Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
® Facility Information
1. System Locati : Rig front of hous , Left/Right rear of house, Left/right side of house, Left/
Right side of bu eft/Right f onf6i building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner:
Name Ns
Address(if different from location)
Cityfrown ' Stat _.r r Cade
m"
F
Telephone Number
t
i
B. Pumping Record
1. Cate of Pumping date 2. Quantity Pumped: Canons
3. Type of system: El Cesspool(s) Ergeptle Tank ® °Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Yes o If yes, was it cleaned? Yes No
" 5. Condition of System: C
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Sateson Enterprises Inc
Company
7. Lo ' e contents were disposed:
7G Lowell Waste Water
Sign toe]Haute Cate 4—
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