HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 316 RALEIGH TAVERN LANE 5/17/2021 :1\_1 Commonwealth of Massachusetts RECEIVED
_ City/Town of
System Pumping Record MAY 17 7021
Form 4 OWN OF NORTH ANDOVER
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 hou e, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under e-6k
Address iyC� J�f�I ,( ►4
City/Town State Zip Zip Code
2. System Owner.
Name b
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-tieptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑" No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 1A l�J t L�4_k�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati re content were disposed:
_L S Lowell Waste Water
SignAtute 9t HauleV Date
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