HomeMy WebLinkAboutSeptic Pumping Slip - 146 RALEIGH TAVERN LANE 12/17/2015 • f
Commonwealth of Massachusetts
C4/Town of . p;
System Pumping"Record
Form 4
DEP has provided this form far use4by local Boards of Health. Other fond$tnay' 'a 'used,`bp
the
information must be substantially the same as that provided here. Before using.thl§'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
I. System Location: Left/Right front of house, a' Righ°ealr of hour- Left/right side of house, Left/
Right side of building, Left/Right front of bui4 g Left/Right rear of building, Under deck
Address
-� Q� � � --w • �
CitylTown •. State Zip Code
2. System Owner.
Name
Address(if different from location)
CiryTfown ' State � � � pie ;
Telephone Number
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rr
B. Pumping JRpcord
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? ❑ Yep No 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 Lowell Waste Water
-§ignitu.fe 9t Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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