HomeMy WebLinkAboutSeptic Pumping Slip - 268 RALEIGH TAVERN LANE 6/16/2017Commonwealth of Massachusetts
City/Town of.
System Pumping. Record
Form 4
CEIVE.
JUL0 5 ?Olt
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form' for useby 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 / Right front of house, Left / Right rear of house
Right side of building, Left / Right fn.:int of building, Left / Right rear cif building, Unde
City/Town
2. System Owner
State
Zip Code
Address (if different from location)
City/Town
States
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Typeof system':
D Other (describe):
Date
Cesspool(s)
2. Quantity Pumped:
Gallons
DSck 0 Tight Tank
4. Effluent Tee Filter present? 0 Ye.s
" 5. Condition of System:
6; System Pumped By:
Neil. Bateson
- Name
Bateson Enterprises Inc
Company
7. Loca '.n-we e contents were disposed:
al_ S. Lowell Waste Water
Haule
If yes, was it cleaned? ID Yes CI No
F5821
Vehicle License Number
Date
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