HomeMy WebLinkAboutSeptic Pumping Slip - 46 RALEIGH TAVERN LANE 12/18/2015 Commonwealth of Massachusetts
City/Town of .
System upin car m °mm `
5.
Form 4
information must be substantial) the same as that provided here. Before usln .this Wh*-,P6 it
DEP has provided this form for usetby local Boards cif Health. Other forms mpy ussd b6 th
inform y P � � 9 h�rour, �"
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 Locations C /Righront 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 --
�1 ` Y ._ 1✓
Citylrown state Zip Code
2. System Owner: _
Name'
Address(if different from location)
City/Town ' State Zip Code ;
Telephone Number
.B. Pumping JRecord �.
1. Date of Pumping Date 2. eitity Pumped: Gallons
3. Type of system: El Cesspool(s) Septic Tank El 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.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo tic�rrwhere contents were disposed:
7G L S. Lowell Waste Water
W10A
-Signg qtHaulev Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1