HomeMy WebLinkAboutSeptic Pumping Slip - 301 RALEIGH TAVERN LANE 10/27/2016 Commonwealth of Massachusetts RtcEIVED
City/Town of .
• System Pumping.Record
4 ° Or'r�r:����rl� �rDO..VI"
Form 4 HLALTH DEPARTMENr
DEP has provided this form for use-by local Boards of Health. Other forms 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. InformatioP
1. System Location: Left/Right front of hous , L!ft/ �'� ar h se;Left/right side of house, Left/
Right of building, 1 Right front of bu L!"ft/e ftght r f building, Under deck
g g 9
Address
Cityrrown state Zip Code
2, System Owner.
Name'
Address(if different from location)
Citylrawn ' . '. � Stater��:'' Z�_ da
Telephone Number �+
J
.B. Pumping Ptecord .
1. Date of Pumping Date 2• Quantity Pumped: Gallons —"
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System '�.,,; � � %
�
�r
6. System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locati contents were diseased:
_L Lowell Waste Water
�4VOA.
Sign We it HaulmU Date
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