HomeMy WebLinkAboutSeptic Pumping Slip - 26 SHANNON LANE 10/28/2016 Commonwealth of Massachusetts RECEIVED
_ City/Town of .
System Pumping,Record NOV 15 Z016
FOfl11 4 TOWN OF NUK,a 1°i ANDOVER
H AUTH 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 hoes a Right ar of hous side of house, Left/
Right side of building, Left/Right front of bul Left/Right rear of but mg. Under deck
Address " � �-��
'W
Ctty/rown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown ' State Zip Code
tS'`(
Telephone Number �-+4
.B. Pumping +Record �
1. Date of Pumping bate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Q-8 ptic 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.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locafiyi. �i„heere contents-were disposed:
.S: ! Lowell Waste Water
-4 `
Sign a Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1