HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 317 RALEIGH TAVERN LANE 12/10/2019 RECEIVED
.-C-\ Commonwealth of Massachusetts
of
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City/Town o
System Pumping Record TOWN OF NORTH ANDOW
Form 4 HEALTH DEPARTMENT
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.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 Locatio e-ftJ Right r-f_of house, Left/Right rear of house, Left/right side of house, Left/
Right side of buiNirf, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town Sh" Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town stag
Telephone Number
B. Pumping Record
16
1. Date of Pumping Date 2. Quantity 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 ofSystem:\���
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
jSigne
. Lowell Waste Water
Haul Date
t5form4.docr 06/03 System Pumping Record•Page S of 1