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HomeMy WebLinkAboutSeptic Pumping Slip - 345 RALEIGH TAVERN LANE 11/10/2015 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 house, ig ear of hous' , 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) Citylrown .. State/1 Code Telephone Number B. Pumping Record . 1. Date of Pumping Date 2. Quantity Pumped: Gallons Y 3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No, ' 5. Condition of System-, 6: System Pumped By: Neil.Batesbn F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Location where contents were disposed: L S: Lowell Waste Water CL Sign a cf HauleV Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1