HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 345 RALEIGH TAVERN LANE 7/2/2020 RECEIVED
.-C\- Commonwealth of Massachusetts
City/Town of �1.. ' Ll ;
DOVER
System Pumping Record TOWN OF NORTHDEPARTMENT
Y p g HEALTH DEPARTMENT
Form 4
DEP has provided this form for use=by 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: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address 7
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Cityrrown State Zip Code
2. System Owner
�e__
Name
Address(if different from location)
City/Town State i Zi Code
- fir
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ���� ��� A—
6. System Pumped By:
Neil Bates-on _ F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo �ontents were disposed:
G L WHaul
owell Waste Water
Sign Date
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