HomeMy WebLinkAbout- Septic Pumping Slip - 82 RALEIGH TAVERN LANE 5/1/2019 i
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Commonwealth of Massachuseffs
C I Town of
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System t U
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DEP has provided this form for useby local Boards of-Health., Other form, t;may-be'used,b,ut the
i -must be subst6riffallyr r
locW Board of'Health to determAne the forrh,they use. The System Pumpingr
localthe Board of'Healthr other appmving authority.
Right.A. Facility Inform' ati,on
1. System Location,* Left/ front of house, * r , wry Left I
Right side i i , Left/Right fr6nt of building, build'm" g, Under deck
Address AQ
ail
Cft.vf Town State zip Codet
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2. System Owner. i
Name'
differentfrom location)
CiWrown statv
Telephone Number
B,. Pumping Record
1. Date of Pumping
* w.
Qu
ed: ----------
-61
ate Gallons
I Type-of system.: E] Cesspool(s) [PeoP5epfic T k L_ Tight
Other e *
Filter4., Effluent'Tee Yes was it cleaned? Ej 'Yes, Nio
yes,,
System,5. Condition of System
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6.
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Name, Vehiclei um r
BatesonEhte!p'R wcompany
7. Lontents were disposed.,
i
Lowell
Waste Water
eool
El","cs
Sign HIIUI Date
. , 06,103 System Pumpingr