HomeMy WebLinkAbout- Septic Pumping Slip - 345 RALEIGH TAVERN LANE 10/19/2018 Commonwealth f Massachusetts RECEIVED
City/Town of . �. �
�. ".�
umpin Record ���"
Form
DEP has provided this form for use-by local Boards cf Health. Other forms maybe*used,but the
information,must be substantially the tame as that provided here. Before using.this forth,check with your
i
lord Board of Health to determine the forth they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
1. System Location: Left/Right front of house,o Righ tea�housLeft/right side of house, Left/
Right side of building, Left I Right front of building, Left I Riguilding, Under deck
Ctty/Town � Zip code
2. System owner:
Name'
Address(tf different from location)
CiIwown State f a _p
F vwS
Telephone Number �+ w
f*
B. PPIMP,
Ing Rpeord
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system+`: E] Cesspool(s) tc Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yes o � if yes, was it cleaned? E Yes ® No.
6. Condition of System:
6: System Pumped By:
Nell.Satesbrt ' F5821
Name Vehicle License Number
Sateson Enter rises Ina
Company
t
7. L ere contents-were disposed:
7a Lowell Waste Water
Sign a CrHaulw Dateu
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t6form4.doce 08103 System Pumping Record a page 1 of 1