HomeMy WebLinkAboutSeptic Pumping Slip - 52 BANNAN DRIVE 7/31/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
V
• Bt.. 3 1 2011
TI OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form. for usern local Boards *Of Health. Other forms may be Used, but the
information must be substantially the same as that provided here. Before using.this forrn, 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 house, Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right frOnt of building, Left / Right rear cif building, Under deck
Address
' '.(\00". Dr Air
City/Town
2. System Owner
State
Zip Code
Narne.
Address (if differentfrom location)
City/Town '
fr
State
z_
Telephone Number
—• '
B. Pumping Record
1. Date of Pumping
3. Type•of system: 0
Other (describe):
47 •
2. Quantity Pumped:
Date
Cesspool(s)
Gallons
El-SeptiCT-ank D Tight Tank
4. Effluent Tee Filter present? D Yes afro"
' 5. Condition of System:
If yes, was it cleaned? 0 Yes 0 No,
6. System Pumped By:
Neil Bateson •
" Name
Bateson Enterprises Inc
Company
7. Location he e contents were disposed:
r
Sign Hbul Lowell Waste Wate
4.•
F5821
Vehicle License Number
Date
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