HomeMy WebLinkAboutSeptic Pumping Slip - 317 RALEIGH TAVERN LANE 12/13/2016 nth Chu n RECEIVED
City/Town of
' tem Pumpling.Record
Form 4 TOWN OF NOWP H ANDOVER
D P has provided this fora for us&by local Boards 'of Health. Other forms may be'used, but the
information-must be substantially the tame 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 kcal Board of Health or other approving authority.
A. Facility. Information
1. System Location L -�Ri coin f hous' , Left/Right rear of house, Left I right side of house, Left f
s Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address c� yu._
City/T-own Mate Zip Code
2. System Owner:
Prarrre•
/address(if different from location)
City/Town Mate' � �� Z ip m)
Telephone Number
Pumping r
1. Date of Pumping Crate 2. Quantity Pumped: ;
Gallons ��"
. Typa-of systern' El Cesspool(s) Septic Tank El Tight Tank
[:1 Other(describe):
4. Effluent Tee Miter present? es No If yes, was it cleaned? [ ff No,
5. Conditio of stern: -
.
6. System pumped Sy:
Nell.Sat an - F5821
Name Vehicle Llcense Number
Sate�te rises Inc
Company
7. Location vuhere contents were disposed:
+ LS: Lowell Waste Water
Sign a hlaule Cate
l5fcrm .doc-08103 System Pumping Record gage 1 of 1