HomeMy WebLinkAbout- Septic Pumping Slip - 344 RALEIGH TAVERN LANE 9/24/2018 i ..Commonwealth f hru ...�;�
ty/Town f .
to• ping. .Record :� .J� �
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DEP ha'provided this ford for use-by local Boards crf Health. Other forms may be'used,but the j
information•must be substantially the game as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. The System pumping Record must be submitted ter
the local Board of Health or outer approving authority.
FacURY InforMation
1. System Location: Left/Fight front of Mouse, Left/Fight rear of house •� iMe!
ds of hous Left
Fight side of building, Left/Right front of building, Left/Fight rear of building, r
Address
cityrrown state zip Code
2: System owner:
Name'
Address(if different from location)
City/Town State'J -- �7 t Zlp�
R `�
Telephone Number
Pumpling Rpcord - '
c�, ,-- �-? -A
1. Date of Pumping late 2. Quantity Pumped: f
��✓✓ Gallons t
3. Type-of systerrr: Cesspool(s) peptic Tank Tight Tank r.
Other(describe):
4. Effluent Tee Filter present? es ® No If yes, was it cleaned? es ❑ No,
a. Condition of System:
Po bV_� .
6, System Pumped By:
Nell.Batesbn F6821
Name Vehicle license Number
_Bateson Enterprises Inc,
Company
7. Locati where contents-were disposed:
G L Lowell Waste Water /
S1gn a Hhule Date
tMorm4.doo-06/03 System humping Record a page 1 of 1 I