HomeMy WebLinkAboutSeptic Pumping Slip - 136 RALEIGH TAVERN LANE 9/8/2015 _ Commonwealth of Massachusetts
_ City/Town of .
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 Location: Left/Right front of hous ,;L!:'#Y Righ ear of hou Left/right side of house, Left/
Right side of building, Left/Right front of b , Left/Rig t rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
cityfrown Stat Zi Cod
Telephone Number
i
B. Pumping Record G� �.
� � �"
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ptic eTank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: n � �
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo ticra'o vih re contents were disposed:
GL_ S: 1 Lowell Waste Water
Sign a Haule Date
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