HomeMy WebLinkAboutSeptic Pumping Slip - 22 RALEIGH TAVERN LANE 7/31/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
c
7tx141001
‘TorN..ri o.tF4t400spFaxR14 Nun
DEP has provided this form for use.by local Boards Of Health. Other forms may be Used, but the
information -must be substantially the same as that provided here. Before using.this forrn, check with your
local Board of Health to determine the forth they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location ront4fi9m 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
Zip Code
2. System Owner
Name'
Address (if different fro
City/Town
B. Pumping Record
1. \r1
Date of Pumping Date 2. Quantity Pumped:
State—)
> C)6)
Telephone Number
11
Gallons
3. Type•of system': El Cesspoot(s) eiS"-igank 0 Tight Tank
El Other (describe):
4. Effluent Tee Filter present? 0 Yes
' 5. Condition of stem:
Z;•,(-
6; System Pumped By:
Neil Batesbn •
" Name
Bateson Enterprises Inc
Company
7. Locati n-w ere contentswere disposed:
S. Lowell Waste Water
• -:-
Signt e. Haul
If yes, was it cleaned? CD Yes 0 No,
F5821
Vehicle License Number
Date
1.5form4.doc• 06/03 System Pumping Record • Page 1 of 1