HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 146 RALEIGH TAVERN LANE 5/3/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
b System Pumping Record Ay o 3 2022
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may *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 tc
the local Board of Health or other approving authority.
A. Facility Information
1, System Location: Left/Right front of house, Left/ ear of sle, Left/right side of house, Left
Right side of build'in , Left!Right front of buildiri , Left/ gh rear building, Under deck
on the computer, /H —
use only the tab
key to move your Address �//�� � /�/
cursor-do not 7t)6&J - 4 MA C C�
use the return CitylTown State Zip Code
key.
2. Sys m Owner:
Name
ienm 4; ,
Address(if different from location)
MA
CityFTown State y Zip Code
TeleoKorie Number
B. Pumping Record
1. Date of Pumping 6 2. QuantityPumped: !� �
p g Date p Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Y No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
I vVi2�''v�l
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7.9L7
where contents were disposed:
Lowell Waste ater
Signature of Hauler Date