HomeMy WebLinkAbout- Septic Pumping Slip - 286 RALEIGH TAVERN LANE 1/7/2019 Commonwealth of Massachusetts
R y City/Town of
System M.
c
Pumpingr
DEP has provided this form for use-by local Boards of Health. Other forms may'be'used,but the
information-roust be substantially the tame as that provided here. Before using.this foram,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted t®
the local Board of Health or other approving authority.
A. Facility information
1. System Location: Lift I Right front of boos , e Right ar� s. Left/right side of house, Left J
Right side of building, Left Right front of bul frig, Left/Eight rear of building, Under deck
Address
clty/Town state Zip Code
2. System Owner: ,
Name
Address(if different from location)
Cityrrown State- -orj l
`telephone Number
Pumping nn r
1. bate of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank 0 Tight Tank
E] Other(describe):
4. Effluent Tee Filter presentI. 0 Yes o If yes, was A cleaned? ® Yes ® No
. Condition of Systenn•
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle license Number
Bateson Enterprises Inc-
Company
7. Locati ere contents-were disposed:
S Lowell Waste Water
Sign a Hhule Crate
t5fbrm4.doc-06/03 System Pumping Record m Page 1 of 1