HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 296 RALEIGH TAVERN LANE 7/22/2020 Commonwealth of Massachusetts RECEIVED
City/Town of JUL 2 2 20?
System Pumping Record TOWN OF NORTH ANOOV€R
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/ side of hous , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under ec c
Address
City/Town state Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State ��J Am Code
Telephone Number
B. Pumping Record
7 �- c3 -aoad CSC
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [ 'Yes LJ No If yes, was it cleaned? es ❑ No
5. Condition of System: �Q�� \ ✓��+ �
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location wheme ontent§were disposed:
G L S Lowell Waste Water
Sign We Haul Data
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