HomeMy WebLinkAboutSeptic tank - Septic Pumping Slip - 317 RALEIGH TAVERN LANE 1/14/2021 Commonwealth of Massachusetts RECEIVED
City/Town of JAN 1 a 2071
System Pumping Record
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 LocationLCeft!Right ifon o h se, 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 A �� �� '
�-� �,
`
Ciwrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State Zip Code
1z Z
Telephone Number
B. Pumping Record
1. Date of Pumping 1 (`� QC-' 2. Quantity Pumped: I Sou
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? E( Yes ❑ No If yes, was it cleaned? W/Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location Giher�contents-were disposed:
/G L S. Lowell Waste Water
SignAtufe 4 HauleV Date
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