HomeMy WebLinkAboutSeptic Pumping Slip - 316 RALEIGH TAVERN LANE 6/12/2017 Commonwealth of Massachusetts ID
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�. S stem Pumping.Record
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DEP has provided this form fir use-by local Boards of Health. Other forms maybe' 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. F'acillty, Inform' ation
1. System Location: Left/Right front of douse, Left/Right rear of house, Left/ ht side o h se, Left /
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck.
Address :�2 r �y ,"�., �'`�.��� ��"����,, ..:�"`� , •?S��'`
City/Town � � state Zip Code
2. System Owner: l..-- ,,!J�- A
Name'
Address(if different from location)
Ci /Town
ty State Zi
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Telephone Number !�v
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. Pumping Racord
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1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system: [] Cesspool(s) 'eptic Tank El Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? n Yes ® No,
" 5. Condition of System:
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6. System Pumped By:
Neil Bateson F5821
Name Vehicle Llcense Number
Bateson Enterprises Inc-
Company
7. Lo bqn ere contents were disposed:
L S. Lowell Waste Water
E
S a Haute ®ate
;5farm4.doo•08/08 System Pumping Record•Page 1 of 1
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