HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 RALEIGH TAVERN LANE 5/18/2020 Commonwealth of Massachusetts REC z—VED
City/Town of MAY 18 2020
System Pumping Record T®YUNpF 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 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/
Rig�t side of building�Left/Right front of building, Left/Right rear of building, Under deck
Address
cityffown State Zip Code
2 System Owner.
f�f� �"�'r j") Vy_
Name
Address(if different from location)
City/Town Statep Code
Te el phone Number
B. Pumping Record
1. Date of Pumping '< 2. Quantity Pumped:
Date Gallo As
3. Type of system: ❑ Cesspool(s) Q Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No 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. Location where contents were disposed:
G L SQ Lowell Waste Water-
SignAtute 9t Haul Date
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