HomeMy WebLinkAboutSeptic Pumping Slip - 146 RALEIGH TAVERN LANE 5/1/2017F5821
Vehicle License Number
Commonwealth of Massachusetts
City/Town of
ystern 11 , -ecord
F
DEp has provided this'll ir"M for usel,v local Boards of Health. Other forms may be Used, but the
4
u ia, V I V L),,l'i,iMIL.,V4 r
information must be substantially the same as that provided here. Before using.this forrn, 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 I for anon
1. System Location: Left / Right front of hou , L Rig1aofhoue", Left / right side of house, Left /
Right side of building, Left / Right front of builierig, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
Name
L.
Address (if differentrom location)
City/Town
P
g Rpc
1. Date of Pumping
3. Type of system':
LJ Other (describe):
•
Date
Cesspool(s)
State
Telephone Number
2. Quanh u ped:
Gallons
ptic Tank Ej Tight Tank
Erg----------
4. Effluent Tee Filter present? CI Yes o If yes, was it cleaned? 0 Yes 0 No,
. Condition of Syst
6: System Pumped By:
Neil. Bateson
Name
Bateson Enterprises nc
ompariy
7. Locatios ere contents were disposed:
Lowell Waste Water
Sign Date
t5forrn4.doc• 06/03 System Pumping Record • Page 1 of 1