HomeMy WebLinkAboutSeptic Pumping Slip - 268 RALEIGH TAVERN LANE 6/27/2016 Commonwe.alth hu
Cit�/Town of
YS
Form 4
'rOW114 U, 11
DEP has provided this form for use=by local Boards 'of Health. Other forma maybe*usect,�but,the
information must be substantially the tame 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.
A. Facility, Information
t.
1. System Location: Left/Right front of house Left Right ht rear of hous e W xrigh�uside�oGh'o�u.s e`
,';Left
Right side of building, Left Right front of building, Left/Right rear of ldin g, Un -4&-- /
Address
! y
....
C%firown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown ' State
Telephone Number `4
13. Pumping Record
c try �w
1. Date of Pumping sate 2. Quantity Pumped:
Gallons
3. Type-of system; ❑ Cesspool(s) is-rank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? �
p ❑ Yes � o If yes, was it cleaned? ❑ Yes ❑ Na,
5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location,where contents were disposed:
^L- Lowell Waste Water
Sign a Haule Date
t5form4.doc•06/08 System Pumping Record*Page 1 of 1