HomeMy WebLinkAboutSeptic tank - Septic Pumping Slip - 224 RALEIGH TAVERN LANE 8/16/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of
UG 16, M
System Pumping Record MW OF Ti AWOVM
Form 4 7" T
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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/Flkjh t rear of h Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner. ,(
Name
Address(if different from location)
City/Town State Zip _
Telephone Number
B. Pum;ping Record
-tea, /
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 Lam'No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
L�'- ",\&cz-
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locgon where contents were disposed:
G L Sr Lowell Waste Water
Signitute fHmulwuDate
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