HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 296 RALEIGH TAVERN LANE 8/2/2019 VSID
Commonwealth of Massachusetts ' CI
City/Town of
System stem Pum in Record
y N 9 of�o�cw �NT
Form 4
DEP has provided this form for umby local Boards of-Health. Other forms may be•used,but the!
information-must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Loft/Right front of house, Left Right rear of house, L �ght s o /
Right side of building, Left/Right front of building, Left/Right rear of build'm ,
Address
1
Cityfrown state Zip Code
2. System Owner.
Name
Address(W different from location)
_Ciwrown g Zip Code
Telephone Number
.B. Pumping Record
1. Date of Pumping Data 2 Quan'Y Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes,was it cleaned? Ll`dg U No
5. Condition of System:e J
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Ehterprises Inc
Company
7. Locatio contents-were disposed:
CAE S: Lowell Waste.Water
Sign a Haut Date
0=4.doc•06/03 System Pumping Record•Page 1 of 1