HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 357 RALEIGH TAVERN LANE 9/13/2021 .&\- Commonwealth of Massachusetts RECEIVED
City/Town of SEP .13 11.021
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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 hous Left/Ri9gttt rear of housa, Left/right side of house, Left
Right side of building, Left/Right front of bWkff g, LeftTMg-- Mar-6#building, Under deck
Address <-�'D I
Cityrrown State Zip code
2. System Owner.
Name l l
Address(if different from location)
City/Town State I Zip
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: (Salton
3. Type of system: ❑ Cesspool(s) 0 Septic Tank ❑ Tight Tank
❑ Other(describe):
i
4. Effluent Tee Filter present? ❑ Yes [a'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: �-
6. System Pumped By:
W
P - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G L S Lowell-Waste Water
Sign Date
5form4.doa 06/03 System Pumping Record•Page 1 of 1
