HomeMy WebLinkAboutSeptic Pumping Slip - 268 RALEIGH TAVERN LANE 7/23/2018 RECEIVED
Commonwealth of Massachusetts
tiCity/Town of . JUL "°018
Form 4 HrAdJ14 DO
DEP has provided this fora for use-by local Boards of Health. Other forms may'be'used,but the
informations must be substantially the tame as that provided here. Before using.this form,check with your f
local Board of Health to determine the farm they use. The System pumping Record must be submitted to t
the local Board of Health or other approving authority. ;
• f
A. Facility. information ,
1. System Location: Le.t/Right front pf house, Left/Right rear of house e rig Idc h+ ho ssp left I
Might side of building, Left/Right front of building, left/Right rear of bui0Q, Uf �. -
Address r_ .a
Citylrown — - State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityfrown ' '. � State% �.k �. C�e� /
1, w
'telephone Number
Pumping r
1. Gate of Pumping Date 2. Quantity Pumped: Canons
3. Type-of s
yp y.stem:
E3 Cesspool(s) Septic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? 0 Yes ® No,
' S. Conditiot f System:
6.• System Pumped By: l
Neil.Bateson F6821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca` ere contents-were disposed:
C S Lowell Waste Water
' W} / r..+."_1 L„µms-*-..-f”�� • F
Sign a Hbul Crate
lftrmCdoc•06103 System Pumping Record®Page 1 of 1