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HomeMy WebLinkAboutSeptic Pumping Slip - 22 RALEIGH TAVERN LANE 10/6/2016 Commonwealth of Massachusetts Clt //�aWn of � � mrr e M r ,,,o�, J° � ������wad� �w,� h. System Pumping.Record 11 01 Form. 4 y @fy{ t py u� DEP has provided this form for use.by focal Boards of Health. Other forms may-IJ6 used, but the information must be substantially the same as that provided here. Before using.this form, * heck 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 /Righti t o� f House Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town state Zip Code 2. System Owner. Name• _ Address(if different from location) Citylrown ' State Zin Code Telephone Number c r x, ping fecord . 1. .... � .,_ 1 1. Date of Pumping C�Data 2/Septic Quantity Pumped: canons i 3. Type�of system. ❑ Cesspool(s) Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of System: Vt 6. System Pumped By: Neil.Bates ri F5821 Name Vehicle License Number Bateson Enterprises Ina Company 7. Locationwhere contents were disposed: .L Lowell Waste Water F Signith4e Haule Cate t5form4.doc•06/03 System Pumping Record•Page 1 of 1