HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 RALEIGH TAVERN LANE 11/30/2020 _ Commonwealth of Massachusetts RECEIVED
City/Town of NOV 3 0 20Z0
System P-umping Record
Form 4 TOWN OF NORTH ANDOVER
�. 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 housk righ de of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 6J-7
CWTown ` State Zip Cotle
2. System Owner.
Name
Address(if different from location)
Cityfrown State„� Code
Telephone Number
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? [3-'Y'es ❑ No If yes, was it cleaned? es No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
L S. Lowell Waste Water
jigg-AW"e— Haul Date
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