HomeMy WebLinkAbout- Septic Pumping Slip - 136 RALEIGH TAVERN LANE 9/24/2018 Commonwealth
ro City/Town of
M •
aSy6tem Pumping.Record
Form 4
1
l3EP has provided this fora for use.by local Boards of Health. Other forms maybe'used,but the
Information,rest be substantially the tame as that provided here. Before using.this fora,check with your
local Board of Health to determine the form they use. The system Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility information ".
{
1. System Location: Loft/Right front of Mouse, a tght e�rear
, Left/right side of house, Left
Right side of building, Left/Right front of building, Left//Rbuilding, Under deck
. Address
city/Town State Zip Code
2. System Owner:
Address(if different from location)
cityrrown ' $tat Zip cc
_ a t Lf
•
Telephone Number ,
Pumping or f
1. Rate of Pumping 2. (,quantity Pumped:
Date Gallons
3. Type-of system: CJ Cesspool(s) eptic Tank E3 Tight Tank f
• f
® Other(describe):
4. Effluent Tee'FlIter present? Yes �NoIf yes, was it cleaned? ❑ Yes ® No.
6. Condition of System:
6. System Pumped By:
Neil.Eatesibn ' F6821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
t
7. Location where contents-were disposed:
.L S Lowell Waste Water
Sign a We3ul Crate
t6form4.doc•06/03. System Pumping Record d Rage 1 of 1