HomeMy WebLinkAbout- Septic Pumping Slip - 317 RALEIGH TAVERN LANE 1/8/2019 Commonwealth of Massachusefts
City/Town of
System Pumplono Record
Form 4
DEEP has provided this form for use-by local Boards of Health. Other forms may bebsed,but the
infbrmafion�must be substantially the game as that provided here. Before using.this form.,check with your
local Board of Health to determine the forrin they use.TbaSystern Pumping Record must be submitted to
the local Board of Health or other approving authority,
A. Facility InforMation
1, System Locatlon�t*A-1 Right:q!@jfq,-f-h—ou—se,,,Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right frontof building, Left/Right rear of building, Under deck
-Address
city/Town stafti, �—Zip Code
2. System Owner:
r-L�7t
Noma'
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
.13. Pumping Record
2 so
1. Date of Pumping Date Quantity ty Pumped: Gallons
3. Type-of system: El Cesspool($) ESeptic Tank Tight Tank
E3 Other(describe):
4. Effluent Tee Filter present'? ayes El No If yes, was it cleaned? M/Yes Ej No
5. Condition of System:
6. System Pumped By:
Neff.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location. ere contenta were disposed:
Lowell Waste Water
Sign Attie f—Hbujtn�j ate
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