HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 BANNAN DRIVE 11/27/2019 .4C\ Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record Nov 2 7 2019
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use:by local Boards of Health.Other forms maybeused,but the
information must be substantially the same as that provided here. Before using.this form,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-K i ht side of side su Left
Right side of building, Left/Right front of building, Left/Right rear of building, n er ec c
Address
City/Town �! ` State Zip Code
2. System Owner. �I
Name'
Address(if different from location)
Gtyfr°wn state- '
Telephone Number
B. Pumping Record �
1. Date of Pumping Elate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) pt c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L°f'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By.-
Nell.Meson F5821
Name Vehicle Ltoense Number
Bateson Enterprises Inc
Company
7. Location Wherp contents-were disposed:
"161_L S Lowell Waste Water
A����(�aA. I C (
SignAje qf Haul Date
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