HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 BANNAN DRIVE 7/1/2020 Commonwealth of Massachusetts RECEIVED
= City/Town of
System Pumping Record Jul- o 202u
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 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 i rear of hour. Left/right side of house, Left/
Right side of building, Left J Right front of building, Left/RlgFiftear of building, Under deck
Address
City/Town State Zip Code
2: System Owner.
Name
Address(if different from location)
Cityfrown State < Zip Cade
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L i'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents.were disposed:
G L S� Lowell Waste Water
— — �
-C—M a- )).
SignAtute 9t HauleV Date
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