HomeMy WebLinkAboutSeptic Pumping Slip - 263 RALEIGH TAVERN LANE 8/21/2017 Commonwealth of Massachusetts
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City/Town of .
System Pumping.Record 1 2 0 11
Form 4 TOWNS OF NORTH ANDOVER
R
MENT
HEALTH DEPXRT
DEP has provided this form for use-by local Boards of-Health. other form's maybe bsed,but the 1
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. Facilify. Information.
1. System Location: Loft/Right front of house, Left Ri ff rear of hou`s` a Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town state Zip Code
2. System Owner.
C
Name'
Address(f different from location)
city/Town ' State- Zip Code
t Telephone Number
r
i
t'r
Pumping Record
i
1. Cate of Pumping - (o
umped:
4 Gallons
P g Date Quantity P
3. Type-of system: Cesspool(s) Septic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? ® Yes ❑ No,
5. Condition of System:
oCvtAej-
6. System Pumped By:
Nell,Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
?. Location where contents.were disposed:
L S. Lowell Waste Water
( c) l4
Sign a FI�u1e Date
t5formet.doc-05/03 System Pumping Record•Page 1 of 1