HomeMy WebLinkAboutSeptic Pumping Slip - 296 RALEIGH TAVERN LANE 7/31/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
TOWN OF NORTH A
HEALTH DEP, *
DEP has provided this form. for use.by local Boards Of Health. Other forms may be used, but the
informationmust 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. Facility Information
1. System Location: Left / Right front of house, Left / Right rear of house, LeftfHht sicle_oftouse, Left /
Right side of building, Left / Right frOnt of buildirig, Left / Right rear of building, Under deck
Address rTh
City/Town
2. System Owner:
State Zip Code
Name'
Address (if different from location)
City/Town Stat
Zip Code
Telephone Number
B. Pumping Record
(i
1. Date of Pumping 2. Quantity Pumped:
Date Gallons /
3. Type.of systems. Ej Cesspool(s) ' ErtTank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? Ercre; 0 No If yes, was it cleaned? Ertl No,
5. Condition ogyAi : ,.._ c ec2,..L
C
i ..r.). 6 -) e._)
kN, (--&-)-e
6: System Pumped By:
Nell Bateson
• Name
Bateson Enterprises Inc.
Company
7. Location wherecontents were disposed:
F5821
Vehicle License Number
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1