HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 216 RALEIGH TAVERN LANE 5/24/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record MAY 2 4 2021
Form 4 TOWN OF NORTH ANDOVER
HEALTH DM,,RT'1cn,r
DEP has provided this form for us&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/ fight [ont of hou eses Left/Right rear of house, Left/right side of house, Left/
Right side of bui! I g, Left/ Rightht of ilding, Left/Right rear of building, Under deck
Address c�- I C/ _O PG t ��--}��J��r� `( ��N
l-Q� l �'V -�
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
CityfTown State M e
�2
Telephone Number
B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Lll, o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo Ation,�ulm�re contents-were disposed:
*�_ Lowell Waste WaterSig Date
t5form4.doaw 06/03 System Pumping Record•Page 1 of 1