HomeMy WebLinkAboutSeptic Pumping Slip - 224 RALEIGH TAVERN LANE 12/11/2017 : Commonwealth of Massachusefts
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System Pumping Record
Form 4
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 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. Faci-I%ty Information
1. System Location: Leff/Right front of douse, Left/C14 t�ofhq0, LeftI right side of house, Left I
Right side of building, Left 1 Right front of buildirig, Left building, Under deck
Address
City/Town l T State Zip Code
2: System Owner F0�
Name'
Address(if different from location)
CityTrown �jp Cade
c�
Telephone Number
t
.B. Pumping Record
7. Date of Pumping pate 2. Quantity Pumped: Lallans
3. Type-of system: ❑ Cesspool(s) ptic Tarek ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o if yes, was it cleaned? ❑ Yes ❑ No,
b. Condition of System-
6; System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location re contents-were disposed:
JG, S: Lowell Waste Water
GD----Ct - C`7 HlulMU
late
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