HomeMy WebLinkAboutSeptic Pumping Slip - 146 RALEIGH TAVERN LANE 5/1/2018 CEIVEU
u E
Commonwealth
City/Town , MAY 018
Sy,4tem Pumping.Record TOWN OF NOW H ANOOVER
®EP 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 forrh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. d-1 • C ft
1. System Location: Lefik/Right front of nous , e�hl ig eer Yoh h" , Left/right side of house, Left I
Right side of building, Left/Right front of b ing, Left/Right rear of building, Under deck
Address `
Cibyyfrown T " State Zip Code
2: System Owner:
Name'
Address(if different from location)
City/Town State- Cad®
Telephone Number C✓ r
r
p : 1 co
1"
c.:
1. ®ate of Pumping Date �QuPumped: Gallons3. Type-of system; ❑ Cesspool(s) k ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it Cleaned? ® Yes ❑ No,
5. Condition of System: �
6.• System Pumped 6y:
Neil.Sat i n - F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lo 'on, 116re-c ntents.were disposed:
L S: Lowell Waste Water
Sign a Houle bate F
t5fbrm4.doca 06/03 System Pumping Record a Wage 1 of 1