HomeMy WebLinkAboutSeptic Pumping Slip - 22 RALEIGH TAVERN LANE 10/6/2016 Commonwealth of Massachusetts
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System Pumping.Record 11 01
Form. 4 y @fy{ t py
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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:
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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
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