HomeMy WebLinkAbout- Septic Pumping Slip - 385 RALEIGH TAVERN LANE 10/31/2018 :-(......
Commonwealth of Massachusetts ...
City[Town of
0C], 13 1
System Pumpling Record
TUMI OF L�,GUTc i,kft)OVER
Form 4 HF:AUTH D[J,11T�l UI[ENT
DEP has provided this form for use.by local Boards of Health. Other forms maybe*used,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 forth they use.TbaSystern Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Factilty In for m' siflon
1. System Location: Left/Right front of house, Left/Right rear of.house, Left right side of house, Left I
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address
C*dyf rown state Zip Code
2. System Owner
Name'
Address(if different from location)
CltyfTown State, zi
Telephone Number
.B. Pumping k9cord
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system., Ej Cesspool(s) 0-a�pficTank El Tight Tank
0 Other(describe):
- .--
4. Effluent Tee Filter present? C] Yes GJb N If yes, was it cleaned? El Yes [I No
5. Condition of System:
V\-
6. System Pumped By.
Nell.Batesoo F6821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati re contentswere disposed:
G,=LQ Lowell Waste Water
7 -
sign fH—hula F
U ate
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