HomeMy WebLinkAboutSeptic Pumping Slip - 216 RALEIGH TAVERN LANE 1/12/2016 l
Commonwealth of Massachusetts
City/Town ®f .
y• to 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/Rh9ilignt 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 f
City/Town state Zip Code
2. System Owner: , . •, , ;o;
Name
Address(if different from location)
City/Town Stat
__4p Code
Ir
Telephone Number ,
B. Pumping Record
1. Date of Pumping Date ;;2. Quant' mped:
Gallons
3. Type-of system. ❑ Cesspool(s) eptic 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 onirh re contents were disposed:
G L S. Lowell Waste Water
Sign a Haule Date
t5form4.doc 06/03 System Pumping Record+Page 1 of 1