HomeMy WebLinkAboutSeptic Pumping Slip - 54 STERLING LANE 11/10/2016 (2) Commonwealth of Massachusetts
RECEIVED
City/Town of .
System Pumping, Record � �� � � y ���
Form 4 'TOWN OF NORM ANDOVER
HEALTH DEPAKM NT
DEP has provided this form far use-by local Boards of Health. Other form's 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/ ift�ht rear of hour;Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/ ight rear of building, Under deck
Address a,
cityfrown
State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State Zip Code
r4
Telephone Number
i
.B. Pumping ✓Pecord
1. Date of Pumping 2. Quantity Pumped:
Gallons ,-
3. Type-of system: ❑ Cesspool(s) ptie Tank ❑ Tight Tank 1.
❑ Other(describe):
4. Effluent Tee Filter resent?
p ❑ Yes If yes, was it cleaned? ❑ Yes ❑ Na
' S. Condition of System:
No� fm� I -� � •
� -�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Locatio where contents were disposed:
G L S'.P Lowell Waste Water
Sign a Haul Date `
t6f6rm4.doo•06/03 System Pumping Record•Page 1 of 1