HomeMy WebLinkAboutSeptic Pumping Slip - 345 RALEIGH TAVERN LANE 9/26/2017 Commonwealth of Massachusetts 40
x W City/Town of .
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w Mean P'�umping.Record �� °?.6� �
Form 4 00
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 farm,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. Facill.ty, InfcrMafion .
9. System Location: Left I Right front of douse, e J Righ rear of hoes , Left/n t-side-of-ho
Right side of building, Left I Right front of buil Ing, Left l lg rear of buildin nder
Address .7
� t
Cityfrown State Zip Code
I
2. System Owner:
L_6ZA�L
#
Name'
Address(if different from location)
CitylTown ' State•, a,7,pp Co
Telephone Number
. Plumping Kecord
9. ®ate of Pumping gate 2. Quantity Pumped: Gallons
3. Type-of system: ® Cesspool(s) ptie Tank ® Tight Tank
® Cather(describe):
4.. Effluent Tee Filter present? ® Yes o If yes,was it cleaned? ® Yes 0 No,
5. Condition of Syst
6: System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. 4G'
a contents.were disposed:
P Lowell Waste Water
F
Sign a 9f Hiauie1vDate
t5form4.doc•06/03 System Pumping Record•Page 1 of 1