HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 316 RALEIGH TAVERN LANE 5/26/2020 Commonwealth of Massachusetts RECEIVED
• Cityffown of MAY 2 6 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 beused,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./r ght ide of house', Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address _
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown StatT C 7 dr ip Cod
Telephone Number l
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes DATO 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 content&were disposed:
teHiaulo.
S. Lowell Waste Water
SigWuDate
t5form4.dov 06103 system Pumping Record•Page 1 of 1