HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 34 RALEIGH TAVERN LANE 7/19/2021 �_ Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record JUL 19 Z071
Form 4
TOWN OF NORTH ANDOVER
HEALjH 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 house, Left/tight side of houses Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address k
Cf ( �
CWrown state Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Stat Zip 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? ❑ No If yes, was it cleaned? Q-Y-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:
G/ -L S-P Lowell Waste Water
Sign a Haul Date
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