HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 345 RALEIGH TAVERN LANE 6/2/2021 Commonwealth of Massachusetts RECEIVED
_ City/Town of AN 0 2 2021
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: Left/Right front of house, eff� tig rea of house;Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig of building, Under deck
Address C f
C'wTown Zip Code
2. System Owner.
Name
Address('if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date t Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: �� l��y`�� � n�..�'� � ✓�`�'�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo contentsr were disposed:
G L S Lowed Waste Water
a- —��a-
Sign a Haul ev Date
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