HomeMy WebLinkAboutSeptic Pumping Slip - 345 RALEIGH TAVERN LANE 10/20/2016 Commonwealth of Massaohusefts
City/Town of .
System Pumping.record
!Form 4
�l ! Pi,
DEP has provided this farm for use-by focal Boards of Health. Other forms maybe 6d, but*,th�i
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
1. System Location: Left/Right front of hour "Rig rearrf h se Heft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear oT6uifding, Under deck
Address c
CRY/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown Stat µ � LC a e
C
f Telephone Number +mod
.B. Pumping Record
1. Date of Pumping bate 2- Quantity Pumped; Capons t
3. Type•of system. ❑ Cesspool(s) -e tic Tank `
. p El Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System.
6. System Pumped By:
Neil.Bates-on ' F5821
Name Vehicle License Number
Meson Enterprises Inc-
Company
I
7. Location where contents-were disposed:
G Lowell Waste Water
_661
Sign Date( F
0orm4.doc•06/03 System Pumping Record•Page 1 of 1