HomeMy WebLinkAboutSeptic Pumping Slip - 136 RALEIGH TAVERN LANE 9/26/2017 Commonwealth of Massachusetts
v CWTown of RECEIVED
SYstei<n Pumping.Record ..
r .
` 2017
Form 4 (3
.'
TOWN OF NORTH ANDOVER f
DEP has provided this farm for use-by local Boards of'Health. Other forma may,b9'usMkbuWftRTMENT
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 Informi ation
1. System Location: Left/Right front of Mouse, lig , eat o hous , Left/right side of house, Left/
Right side of building, Left/Right front of bur ing, Left/R g rear of building, Under deck
Address
City/Town ` State Zip Code
2.. System owner.
Name
Address(if different from location)
City/Town ' State q/Zip d
Telephone Number
. urn�ping Record C..
1. Crate of Pumping pate �� �Qu�2. lily Pumped. Gallons3. Type of system: ❑ Cesspooi(s) ank [I Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E]- o If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste
(LOA V I
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatipra-w re contents were disposed:
�L .w,J Lowell Waste Water
Sign a qf Haule Date
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