HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 344 RALEIGH TAVERN LANE 7/1/2020 F
Commonwealth of Massachusetts RECEIVED
City/Town of JUL 0 12020
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 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 hous. g side_ of Ouse, eft l
Right side of building, Left/Right front of building, Left/Right rear of bul ding, Under deck
Addresses ��Y.v As �•-� _�
cityRown State Zip Code
2. System Owner.
Name
Address(if different from locafion)
CitylTawn State`a�.�: Tr_p Code_
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) (3-89-pIc-Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? EPf6s-�[] No If yes, was it cleaned? [12.� No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati re contents-were disposed:
L S Lowell Waste Water
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Sign We fHaulmU Data
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