HomeMy WebLinkAboutSeptic Pumping Slip - 70 RALEIGH TAVERN LANE 11/17/2015 Commonwealth of Massachusetts
_ City/Town of .
System Pumping-Record
Form 4
DEP has provided this form for use4 by local Boards of Health. Other forms may be Lsed, 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/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown �- State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town ' State _ Zip Code ;
Telephone Number
t
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Canons
3. Type-of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo ti=her contents were disposed:
G L Lowell Waste Water
Signitufe 9t HaulerU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1