HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 82 RALEIGH TAVERN LANE 5/18/2020 : Commonwealth of Massachusetts RECF_IVE®
City/Town of MAY 1 ZON
System Pumping Record
Form 4 TpWN OF IVURIH ANW �'�
TH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may *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: Rig front o ho , Left Right rear of house, Left/right side of house, Left 1
Right side of building, Left/ o building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State
Telephone Number
B. Pumping Record
1. Date of Pumping oat 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) lc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0_90 If yes, was ft cleaned? ❑ Yes ❑ No
5. Condition of System: C/S � LA, _
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo ere contents-were disposed:
G L S. Lowell Waste Water
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