HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 22 BANNAN DRIVE 10/29/2020 Commonwealth of Massachusetts RECEIVED
_ City/Town of
System Pumping Record OCT 2 9 ?020
Form 4 TOWN OF NORTH ANDOVER
s• 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 ftht rear of house,'Left/right side of house, Left
Right side of building, Left/Right front of building, Left ig rear'of building, Under deck
Address
City[rown State Zip Code
2. System Owner.
Name
Address(f different from location)
City/Town State e
Telephone Number
B. Pumping Record
1. Date of Pumping Daft 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) epic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson _ F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo tion_where contents-were disposed:
G-LLS-P Lowell Waste Water
Signitute c0aul pate
t5form4.doc•06/03 System Pumping Record•Page 1 of 1