HomeMy WebLinkAboutSeptic Pumping Slip - 135 RALEIGH TAVERN LANE 9/11/2017 Commonwealth of Massachusetts RECEIVED
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Otem Pumping.Record
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NORTH aiv
HEALTH DEPARTMENT
MP ha's provided this form for use-by local Boards ofHealth. Other form's may'be'used,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 forr'n they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. facility InforMafion
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1. System Location: Left/Right front of house, Left i ref ar of hause,�Left/right side of house, Left/
Right side of building, Left/Right front of building, Le%Right rear cif building, Under deck
. Address ��.. � • , °CiC.,�'.�2..a� ._` - _.C�...i�°-`^�5.�.
Citylrown state - Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityfrown ' State Zip C
Telephone Number
Pumping Record
1. Date of Pumping pate 2. Quan ity Pumped: Gallons
3. Type-of system: Cj Cesspool(s) eptic Tank El Tight Tank
® Other(describe):
4.. Effluent Tee Filter present? ® Yea ® if yes,was it cleaned? ® Yes ❑ No,
5. Condition of System: butl !
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6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises inc-
Company
7. Locatio here contents-were disposed:
f
Lowell Waste Water
Sign a Hau! Date
0arm4.doe^06/03 System Pumping Record a Page 1 of 1
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