HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 RALEIGH TAVERN LANE 4/9/2021 Commonwealth of Massachusetts
City/Town of
System Pumping Record APR 0 2021
Form 4
(._YIF �HEALTH
DEP has provided this form for use-by local Boards of Health. Other forms maybe used,but the
infbrmation,must be substantially the tame 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
-i f house' Left./right side of house, Left I
1. System Location: Left/Right front of house/f.60 Rig Kre r;o�
Right side of building, Left/Right front of b0ldifig, LeftlWg-ff_rea—rdf building, Under deck
Addms
cityfrown State Zip Code
2. System Owner. S
Name'
Address(if different from location)
cWrown stater �zi
Telephone Number
13. Pumping Record
1. Date of Pumping
Dale 2. Quan
d Pumped:
Gallons
3. Type-of system: E Cesspool(s) ePfiic Tank M Tight Tank
[3 Other(describe):
4. Effluent Tee Filter present.? 0 Yes avo� If yes, was it cleaned? El Yes El No
5. Condition of System:
6. System Pumped By:
Nell Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo a contents-were disposed:
LLSQ Lowell Waste Water
Sig a Haul Data
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