HomeMy WebLinkAboutSeptic Pumping Slip - 332 RALEIGH TAVERN LANE 12/28/2016 w Commonwealth
i own of
r.. * Pumpling.Record "�',➢`�J�i )� CI�YW',It9Ftt6�14.,�t�W�"�.
Form 4
A
DEP has provided this form far us&by local Boards of Health. Other forms maybe*used, but the
information must be substantially the same as that provided here. Before using.this farm,check with your
local Board of Health to determine the farm they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facfla ty. Informadop .
9. System Location: Left/Fight front of douse, Left I Right rear of house, Left• de of houso� Left/
Right side of building, Left/Right front of building, Left/Right rear of building, n er Upk. .
Address
CiRrown State Zfp Code
2. System Owner:
Name'
Address(if different from location) �..
Cltyfrown State �r , Zip Code
Telephone Number
m Pumping Record .
t. Date of Pumping o�te 2. Quantity Pumped:
Gallons
3. Type-of system. Cesspool(s) eptic Tank E Tight Tank
E] Other(describe):
4. Effluent Tee Filter present? g-Ve—p No If yes, was it cleaned? No,
" 5. Condition of Syst rrt:
6. System Pumped By:
Neil.Batesan F5821
Name Vehicle License Number
6ateson Enterprises Ina
Company
7. Location where contents-were disposed:
L
S. Lowell Waste Water
f
Sign a Haule Cate
t5forrmCdo 06/03 System Pumping Record m Page 1 of 1