HomeMy WebLinkAbout- Septic Pumping Slip - 344 RALEIGH TAVERN LANE 4/19/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of APR 19 2022
` b *TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may beused, 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. Sy
tion: Left/Right front of house, Left/Right rear of house, Left/right side of hous ,2Left�
ide building, Left/Right front of building, Left/Right rear of building, Under deck
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on the computer,use only the tab j f-�C Yh, T-19
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key to move your Address
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cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
e-4 1,4 11/W
Name
Bnm
Address(if different from location)
_ MA
Citylrown State `1Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping � 2. Quantity Pumped: /
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe)- -
4. Effluent Tee Filter present?34es ❑ No If yes, was it cleaned- Comes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. L where contents were disposed:
GLSD Lowell Waste Wat
Signature of Hauler Date