HomeMy WebLinkAboutSeptic tank - Septic Pumping Slip - 301 RALEIGH TAVERN LANE 12/7/2020 Commonwealth of Massachusetts
City/Town of 0
v System Pumping Record
Form 4 oFNo��..���M�
s'• q��
DEP has provided this form for use=by local Boards of Health. Other form rfi 6e 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: Leta/Right front of house'
ouse ?inc
/Ri ht ear of hou Left/right side of house, Left
Ri ht side gf b 'Iding, L /Right front of bul , eft tg ear of building, Under deck
t' C Q' I/?"U 11-1
Address
cfwrown State Zip Code
2. Syste Own r.
Name
Address(if different from location) �A
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date I 2- Quantity Pumped: Gallons �tJ
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 14' No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: I
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Sateson Enterprises Inc
Company
7. Login where contenta were disposed:
Lowell Waste Water
J__S4n"e_9f_Haul Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1