HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 296 RALEIGH TAVERN LANE 5/17/2021 RECEIVED
Commonwealth of Massachusetts MAY 1 7 2021
City/Town of
System Pumping Record TOWN T NORTH THEAND TER
in
Y p g HEALTH DEPARTMENT
Form 4
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: Left/Right front of house, Left/Right rear of house, Left/ t side of hous ,Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under ec c
Address
Cttyfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CctylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Q lily Pumped: Gallons
3. Type of system: El Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ales LJ No If yes, was it cleaned? es ❑ No
5. Condition of System:
`t'tk q,(19� C � v�
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle Ltcense Number
Bateson Enterprises Inc
Company
7. Lotz. e contents-were disposed:
G L S Lowell Waste Water
Sign1we 9t Haulau Date
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