HomeMy WebLinkAboutSeptic Pumping Slip - 357 RALEIGH TAVERN LANE 7/19/2016 Commonwealth f Massachusetts
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iffy own of
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Form 4
[CEP has provided this form for use by local Boards of Health. Other forms may be used, butt
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
1. System Location: Left/Right front of house, eI`Rig Wrear of hot�sefLeft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Righ`rear of building, Under deck
Address a —•-.mom
cayfrown State Zip Cone
2. System Owner: ����_
Name'
Address(if different from location)
City/Town ' State y, Zi p die
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7
Telephone Number
i
. Pumping Rgicord
A
1. date of Pumping bate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
...
6: System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. LocafionI a contents-were disposed:
L S: Lowell Waste Water
Sign a cit Houle hate
t5form4.doc-06/03 System Pumping Record•Page 1 of 1