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 5form4.doc• 06/03 System Pumping Record • Page 1 of 1