HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 46 RALEIGH TAVERN LANE 1/31/2022 : Commonwealth of Massachusetts RECEIVED
City/Town of JqN 312022
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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted t(
the local Board of Health or other approving authority.
A. Facility Information
1, System Location: Left/ Right s eft/ 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
on the computer, ` ' )
use only the tab 1/6 (2a 1 �� Tom,,/!/
key to move your Addre s
cursor-do not . ���il t„ r, MA
use the return City/Town �'��-f State Zip Code
key.
2. System Owner:
Name
B�
Address(if different from location)
MA
Cityrrown State Zip Code
/ n/ 7 g�� 2 7 Z
Telep one Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ,Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): — - — —
4. Effluent Tee Filter present?/Ej"�Yes ❑ No If yes, was it cleaned? es ❑ No
5. Observed condition of component pumped:
/UO �Vvv,-/ /due,(
6. System Pumped By:
David Tiney Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed: 1
D owell Waste Water
Signature of Haule Date