HomeMy WebLinkAboutSeptic Pumping Slip - 224 RALEIGH TAVERN LANE 11/3/2016 Commonweaith of Massachusetts
Rt
City/Town of .
System Pumping-Records
Form 4 TOWN OF NOR I H ANDOVER
HEALTH DEPARIMENT
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.fhis form,check with your
local Board of Health to determine the forrim 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, LeftRight rear of ho su deft•/right side of house, Left/
Right side of building, Left/Right front of building, LeffTlght rear cif building, Under deck
Address
city/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' State Zip Code
5 c)
Telephone Number
h
fI
.B. Pumping Pecord
1. Date of Pumping aft I 2 uantity Pumped:
Gallons ,
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:
6r System Pumped By:
Nell Batesbn - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. ocatipn.where contents were disposed:
C L S: Lowell Waste Water
Si
g n e Haule Date
t5f6rm4.dor.-06/03 System Pumping Record•Page 1 of 1