HomeMy WebLinkAboutSeptic Pumping Slip - 296 RALEIGH TAVERN LANE 7/23/2018 Commonwegilth of Massachusetts
City/Town of . JUL2 3 "'(11
ing. r �
• JwJEAawama a Dua.tiIRTMENT
Form 4
®EP ha'provided this form for use-by local Boards of Health, tither 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 Wealth to determine the faun they use.The,System Pumping Record must be submitted E
the local Board of Wealth or other approving authority.
A. fiiInform' sition
1. System Location: Left/Right front of house, Left/might rear of house, Left mLeft
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityl'rown State Zip Code
Z. System Owner
Dame"
Address(if different from 10Cetian)
City/Towo ' state /// 1p Code
Telephone Number
,B. Pumping Rqcord
1. Date of PumpingDate 2. Quantity Pumped:
Gallons�.�
3. Type-of s
Yp Y.sterni:
® Cesspools) pts is Tank ® Tight Tank
Other(describe):
4. Effluent Tee Filter present? 6_?�esll No If yes, was it cleaned? es ❑ No,
' 5. Condition of Syste N'L-
6. System Pumped By:
Nell Batesiop ' F5821
Name Vehicle t.;cense Number
Bateson Enterprises Inc-
Company
7. Luca ` ��conte�tfwere disposed:
Q,�-S: Lowell Waste Water
. f
Sign a blame tate
t5form4.doC«06/08 System pumping Record•Page 1 of 1