HomeMy WebLinkAboutSeptic Pumping Slip - 224 RALEIGH TAVERN LANE 12/17/2015 Commonwealth of Massachusetts
City/Town of
.System Pumping.Record
Form 4 H 1,AJ M,,r i1,11
DEP has provided this form'for use=by local Boards of Health. Other forms may be'used, b'but the
Information-must be substantially the tame 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
I. System Location: Left/Right front of house, Left use, Left/right side of house, Left/
Right side of building, Left Right front of building, Left Right rear of building, Under deck
Address At-Vic)
City/Town state Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityrrown state Zip Code
se)
Telephon6'Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type•of system. ❑ Cesspool(s) a-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee 'Filter present? ❑ Yep No If Yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6.. System Pumped By:
Nell.Batesion F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location:where contents were disposed:
Lowell Waste Water
I
Sign I Te 9t HauleV Date
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