HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 224 RALEIGH TAVERN LANE 4/23/2020 Commonweaith of Massachusetts RECEIVED
City/Town of APR 212020
System Pumping Record TOWN 0�NpKf H ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for us&by local Boards of Health. Other forms may *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, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Myfrown State " \ Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State � '3�� Zi Code
p
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: L
Gallons
3. Type-of system: ❑ Cesspool(s) [a_Se c ank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo hefe<contentsr were disposed:
G L a Lowell Waste Water
Sign a �SA
J.UulmuDate
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