HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 268 RALEIGH TAVERN LANE 9/21/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of SEP 21 2020
System Pumping Record TOWN OF NORT H 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,light tde o house Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Unde
AddressCity/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CityfTown
Telephone Number
.B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped:
Gaallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst \ V^v
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L where contents-were disposed:
G L S Lowell Waste Water
Sign a Haul Date
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