HomeMy WebLinkAboutSeptic Pumping Slip - 316 RALEIGH TAVERN LANE 6/6/2018 Commonwealth of Massachusetts
City/Town of .
�- SY,4t ing-Record JUN 201
DEP has provided this farm for use-by local Boards 'of health. Cather farms may be'used,but the
information'must be substantially the itarne 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 t®
the local Board of Health or other approving authority.
A. Facill.ty. InforMation
1. System Location: Loft/Right front of Mouse, Left I Right rear of house, Left de of , Left
Right side of building, Left/Right front of buildirig, Left/Right rear®f building, Under deck
Address
City/Town state Zip Code
2. System Owner:
' Name'
Address(if different from location)
�.'Itylwrdwn cI$a$e
t '`? zip�ro �
f
Telephone Number
Pumping
1. ®ate of Pumping [tate 2. Quantity Pumped: Gallons r
3. Type-of system: F-1 Cesspool(s) Bleptic Tank Tight Tank x.
❑ Other(describe):
4. Effluent Tee Filter present? Yes a If yes, was it cleaned? ® Yes E] No,
' 5. Condition of stem:
6.• System Pumped By:
Neil,Bateson F5821
Name Vehicle License Number
Bateson Bhterprises Ina
Company
7. Location wr contents-were disposed:
G L S Lowell Waste Water
Ro
� _ �
'signAtje fHOUIMU Cate F
t5form4.doc-06/03 System Pumping Record Page 1 of 1