HomeMy WebLinkAboutSeptic Pumping Slip - 34 RALEIGH TAVERN LANE 10/24/2016 Commonwealth of Massachusetts
City/Town of .
System Pumping.Record
Form 4 '' ;
DEP has provided this form for use•by local Boards of Health. Other forms m rlm"
information•must be substantially the same as that provided here. Before using.this ,%iA 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 douse, Left/Right rear of house, Left/f g=side house,Right side of building, Left/Right front of building, Left/Right rear of building, k----�>
Address 5
Cityfrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
CityPrown state C? --, ip Code
Telephone Number `3
r
.B. Pt;mping Pumping Record
1. Date of Pumping date 2. Quantity Pumped:
Gallons r �"
3. Type-of system. ❑ Cesspool(s) ❑ is Tank ❑ Tight Tank
❑ Other(describe): _
4. Effluent Tee Filter present? p El No If yes,was it cleaned? es ❑ No,
5. Condition of Sys#em
`c
6: System Pumped By: Vu-
Nell.Bateson F5821
Name Vehicle License Number
BateSon Enterprises Ina
Company
7. Location where contents-were disposed:
4SIgne Lowell Waste Water
Haute Date
t5form4.doc•06/03 System Pumping Record Page 1 of 1