HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 BANNAN DRIVE 10/31/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of OCT 312022
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left I QRt ar of house, Left/right side of house, Left
Right side of building, Left/Right front of building, ght rear of building, Under deck
on the computer, (�
use only the tab � nr\&o ® (—
key to move your Address
cursor-do not U. �� MA c)
use the return key. City/Town State Zip Code
2. System Owner:
Name
-_--
Address(if different from location)
MA-
City/Town State Zip Code
1FD-7
Telephone Number
B. Pumping Record
1. Date of Pumping Da 2- 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ] Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): —-- - - -
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
IJ�Cfh� l
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
LSD` well Waste Water
16124 b
Sign auler Date