HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 332 RALEIGH TAVERN LANE 9/7/2021 RECEIVED
:�L Commonwealth of Massachusetts
City/Town of SIP 0 7 2021
System Pumping Record TOWN OF NORTH ANDOVER
Y 9 HEALTH DEPARTMENT
Form 4
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: Le ig rkt ` , Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address (1' __ZrA
C4ylrown State Zip Code
2. System Owner.
Name (�
Address(d diffemnt from location)
Cit0° �L-t
Telephone Number
B. Pumping Record
1. Date of Pumping nay 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) UIeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Llyi;�❑ No If yes, was it cleaned? 9_<�❑ No
5. Condition of Sy's�tel V/ '
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents�were disposed:
tie
Lowell Waste Water
3��r
ul Date
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