HomeMy WebLinkAbout- Septic Pumping Slip - 109 RALEIGH TAVERN LANE 6/24/2019 Comon
m .h
of Massachusefts
RECEIVED
City/Town of
1)
System Pumpf"no Record kN'D0VER
Form 4, TOW I lq I
DEP has provided this
r
r
t
form for use�by local Boards of,Health. Othe!r formt;
localinformation-must be substintially the "same as that provided here. Before using.this form, check with your
rmine the forrh they use.,TheSystem Pumping Record must be submifted to
the local ar r other approving
A. Facil"119ty InforMatison
1
System n: front of house Left It rear of hous 1, Left I right side
Right side of building, Left/1 Riglitl , LQeft R l-g�� ar 6f building, Under deck
Address
City owe state ZipCode
21. System Owner;
Name"
Address(if different from l
clityyTown State.
CN
Telephone Number
1
.B. Pumping
i
Record
Ir N
. Date of '
3-, Type-of system: E), Date Geflonsepr
Other(describe),
ilk r r nth -' Yes
cleaned?
S. Condition
�Ak M,
' .. ..
9
f
. System : I.
,Neil,. 7,
Name Vehicle i
Bateson ELhLeMrlses Ina,
company
f
7.
i
i
l ndisposed:
Lowell Waste Water
Up, e,IfHwl Date
. 'och 06/03 System Pumping Record Page 1 of I