HomeMy WebLinkAbout- Septic Pumping Slip - 301 RALEIGH TAVERN LANE 10/31/2018 ,t Commonwealth of Massachusetts FIECEIVED
City/Town of
System Pumpling Record OCT 312018
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DEEP'has provided this form for usexby local Boards of Health. Other forms maybeused, but the
information must be substantially the tame 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 to
the local Board of Health or other approving authority.
A. Facility InforMation
I. System Location: Left/Right front of hous ght�656-Nffhou s.0 Left/right side of house, Left I
Right side of building, Left Right front of bqu�l�'Slntg, Left Ig 6f building, Under deck
Address
ollyt rown state Zip Code
2. System Owner H
Name'
Address Of different from location)
CiWown
Telephone Number
.B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: El Cesspool(s) E3,15e-pifi-c—Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yes a-`N�o If yes, was it cleaned? El Yes [I No
5. Condition of System:
6. System Pumped By.
Nell.Batesion F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatbio e contents-were disposed:
a Q LS Lowell Waste Water
4-Sgig—ne Hbuiaqate
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