HomeMy WebLinkAboutSeptic Pumping Slip - 82 RALEIGH TAVERN LANE 6/28/2017Cornmonwealth of Massachusetts
City/Town of ECE1VED
System Pumping Record
Forrn 4
• .
DEP has provided this forrn. for use.by local Boards of Health. Other
informationmust 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.
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A. Facility Information
. •
1. System Location.9} / Rightzont hous9 Left/ Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
Cttyfrownql,
2'. System Owner:
de
clover
Zip Code
Name*
Address (If different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Typeof system':
El Other (describe):
4. Effluent Tee Filter present?
5 Condition of System:
Telephone Number
State Zip Code
-SO q11
141 - --Quantity Pumped: Gallons
Date
Cesspool(s) lie Septic Tank EJ Tight Tank
6: System Pumped By:
Neil. Bates -on -
Name
Bateson Enterprises Inc
Company
as No
If yes, was it cleaned? E] Yes El No,
tri44 ( 1.se V C. (
7. Location vvh re contents were disposed:
Lowell Waste Water
Signi
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1