HomeMy WebLinkAboutSeptic Pumping Slip - 781 WINTER STREET 10/28/2016 (2) Commonwealth of Massachusetts
RECEIVED
Cifji/Tawn of NOV 'I gip°
,
System Pumping-Record TOWN OF C�1¢��t II ANDOVER
Form 4 HEALTH DU1�k�'G h�Ea` T
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
I. System Location: Left/Right front of house, Left/Right rear of house, Left!right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
�-4 '. �� .
CWrown State Zip Code
2. System Owner.
Name.
Address(if different from location)
Cityirown ` Stated Zip Code
a Telephone umber r c
r'
.B. Pumping Record
X
1. Date of Pumping bate 2• Quantity Pumped: Gallons k°
3. Type-of system: ❑ Cesspool(s) LD--86pfic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [3140 � if yes, was it cleaned? ❑ Yes M No,
5. Condition of Syste
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati taww N re contents-were disposed:
G L Lowell Waste Water
C-A/VaSA. Bz6z_-e��
G~
i
Sign a I Houle Date
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