HomeMy WebLinkAbout- Septic Pumping Slip - 224 RALEIGH TAVERN LANE 11/26/2018 Commonwealth of Massachusetts
City/Town of „ ry
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System umpi cord
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CEP has provided this form for use-by local Boards of Health. Other forms maybe*used,but the
Information-must be substantially the same as that provided here. Before using.this form,check with your
Ioc6l Board of Wealth to determine the forrh they use. The;System Pumping Record must be submitted t®
the local Board of Health or other approving authority.
A. Facility f r Mation
1. System Location: Left/Right front of House, Left/Right rear of house, Left./right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address � ---- "
-
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown State- Zip Code
Telephone Number
B. in
9, bate of Pumping date 2. Quantity Pumped:
Gallons
3. Type-of system:y stem: ❑ Cesspool(s) eptic Tank Tight Tank
El Other(describe): . .....
4. Effluent Tee Filter present.? ® Yes If yes, was it cleaned? ® Yes El No
5. Condition of System:
6. System Pumped By:
Neil.Batesern F5821
Name Vehicle License[dumber
_Bateson EhteMrises Ina
Company
7. L eat!b°° "here" ontents-were disposed:
L S Lowell Waste Water
Sign a Haul Date
tM m4.docs 06103 System Pumping Record Page 1 of 1
