HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 146 RALEIGH TAVERN LANE 5/18/2020 Commonwealth of Massachusetts ECEIVED
City/Town of MAY 18 2020
System Pumping Record TOWN OF NORTH ANDOVER
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 forrim 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/Bit rear of house, Left/right side of house, Left
Ri t ide of building, Left/ fight front of building, Left/Right rear of building, Under deck
�46 !�M�
Address
City/Town State
2. System Owner. Zip Code
Name'
Address(if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 1
Date 2. Quantity Pumped: Gallons ---
3. Type-of system: ❑ Cesspool(s) Septic Tank
❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
Q No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
vt
6. System Pumped By:
Neil.Bateson Name F5821
Vehicle License Number
_ Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
ge6V
Lowell Waste Water
;Sign Date
t5fbrm4.doc•06103
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