HomeMy WebLinkAboutSeptic Pumping Slip - 201 RALEIGH TAVERN LANE 9/1/2016 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping-Record a ,A
Fdrm 4 .I- 1�OF MOVER
•'� a EAL FME'N i.
DEP has provided this form for use-by local Boards of Health. Other form's 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.
A. Facility. Information « �C ,.
I. System Location: Left/Right front of house, Left/Right rear of house, Left/righf i e of house` Left/
Right side of building, Left I Right front of building, Left/Right rear of building, Unde
Address )
City/Town State Zip Coale
2. System Owner. t
UGC)0 V'1 U�?
Name'
Address(if different from location)
CitylTown Stater iPCoc@(C�tc°' .
Telephone Number
.6. Pumping JRecord
1. date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: M Cesspool(s) ® ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes (+� If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: .oA
6: System Pumped By:
Neil.Bateson 1=5821
Name Vehicle License Number
Bateson Enterprises Inc-
company
7. Location where contents were disposed:
LS'.LS'Q Lowell Waste Water
-h aA 9-
Signitu a HaulerU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1