HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 268 RALEIGH TAVERN LANE 9/7/2021 ..� Commonwealth of Massachusetts
RECEIVED
City/Town of SEP 0 7 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, Left/Right rear of hous. Left'/ ht lde of house Left/
Right side of building, Left/Right front of building, Left/Right rear of bul mg, Under e.
Address cat-�'� ��'(/�`'��21''✓�. I�C�� _ ,�c�
Citylrown State Zip Code
2. System Owner:
Name t
Address(if different from location)
Ciwrown Stater C� ` SL14��et
Telohone Number
B. Pumping record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes UIWO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 00 1'vv` W,� 1 VN, 4z�--Lvk,
6. System Pumped By.
Neil.Bateson _ F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' ere contents-were disposed:
�LSQ, Lowell Waste Water
Sign a Haul Date
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