HomeMy WebLinkAboutSeptic Pumping Slip - 82 RALEIGH TAVERN LANE 7/18/2016 Commonwelafth of Massachusetts
City/Town of Vi
Y
to i ' r�
Form 4
DEP has provided this farm for use=by local Boards of Health. Other forms may be
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
I. System Location;Lp .,f'Righ �rontf hause, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear(if building, Under deck
Address
1,ale 'J, e( , A 01\11t�
Citylrown f C State
• 1 ,, 'p Code
2. System Owner:
Name
Address(if different from location)
CityJTown State Zip Codre� ;
u
Telephone Nmber
y r
. Ppmping Rpc r
1. Date of Pumping 2 uantity Pumped:
Date Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Laclation-whgre contents-were disposed:
G L S: Lowell Waste Water
I-A OA
..,. �
Sign a Haule Date
t5form4.doc-06/03 System Pumping Record.Page 1 of 1