HomeMy WebLinkAboutSeptic Pumping Slip - 344 RALEIGH TAVERN LANE 10/27/2016 Commonwealth of Massachusetts
City/Town of
System Pumping.Record
Form 4 TOWNo
HEAUH L)i PAKI`M NT
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. Informlation
1. System Location: Loft/Right front of house, Left I Right rear of houseC�� right silo of houses Left/
Right side of building, Left/Right front of building, Left/Right rear cif building, Under❑eck---
Address
c: . . �
Cityr/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown state- zip Code
Telephone Number
i
.B. Pumping Record �.
1. date of Pumping rA 2. uantity Pumped: - - ---r
Date Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes [] No if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: 4-
6. System Pumped By:
Nell.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. LoaRtion,where contents were disposed:
�. Lowell Waste Water
lL> 'l ~ 1 f
Sign t e Hsule Date
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