HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 22 RALEIGH TAVERN LANE 11/30/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of NOV 3 0 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 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• a ?/ftht�ntof h use, ft/Right rear of house, Left/right side of house, LeftRight side of buH g, /R'r n o uild'mg, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner. C,:q ( ,,
Name'
Address(if different from location)
CitylTown �� _ e
J�
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
1
5. Condition of System: /Jc*�&_czV
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle t_icense Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
"L S Lowell Waste Water
Signkje cfHaulwU Data
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