HomeMy WebLinkAboutSeptic Pumping Slip - 121 RALEIGH TAVERN LANE 8/15/2018 Commonwealth of MassachusettsRECEIVED
Wf1 of
AUG" "15 2018
Sy,4tem Pumping,Record
Form 4 70 ISI OF 1'1IORTHANDOVEi"°
®EP has provided this farm for use-by local Boards o' F�ealth. Other forms may be'used,but the
information-must be substantially the carne 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.
Facift.ty, Inf r ti J
I. System Locatio ,
Vi�jig fr nth f de, Left/Right rear of house, Left/right side of house, LeftRi ht side of bu it/Ri h runt of building, Left/Right rear of building, Under deck
9 9
Address l t ,� ...�:�...�"",� 4• _.. ��tJ
Gitynown state Zip code
2. System Owner. b
Name'
Address Of different from location)
CityJTown state Id
Telephone Number ;fir
/
Pumpling Rpcord
1, Date of Pumping rate 2. Quantity Pumped:
Gallons
3. T e•of s
Type-of y•stem: El
Cesspool(s) ptic Tank D Tight Tank
[] Other(describe):
4.. Effluent Tee Filter present? El Yes o If yes,was it cleaned? ® Yes ❑ NQ
" 5, Condition of System:
6r System Pumped By:
hleii.Batesran F5821
Name Vehicle License Number
_Bateson Enterprises Inc'
Company
T. Lo fiqWw ere-,�ontents-were disposed:
Lowell Waste Water
f
Sign a Hilularu
Date f
tftrm4.doca 06/43 System Pumping Record.Fane 1 of 1