HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 RALEIGH TAVERN LANE 4/19/2022 RECEIVED
Commonwealth of Massachusetts APR 19 2022
City/Town of
TOWN OF NORTH ANDOVER
System Pumping Record HE�kTHDEPARTMENT
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 yo
local Board of Health to determine the form they use. The System Pumping Record must be submitted
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/ rear of boL4se, Left/right side of house, Lei
Right side of building, Left/Right front of build iri , Left Rig rear building, Under deck
on the computer,
use only the tab
key to move your Address
cursor-do not 4tTX MAuse the return 1key. wn State Zip Code `
2. System Owner:
VQ
N ma e
renm
Address(if different from location)
MA
Cityrrown State Zip Code
Tel one Number
B. Pumping Record
1. Date of Pumping Date �" 2. Quantity Pumped: Gallons
d
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By.-
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. Loc where contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date