HomeMy WebLinkAboutSeptic Pumping Slip - 509 FOSTER STREET 11/12/2016 Commonwealth of Massachusetts
M City/Town of . RECEIVED
System Pumping.Record Nov �1 1 7.016
Form 4
• '101 0 Chi°NU TH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may be bsed, 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/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 r
City/Town State Zip Gode
2. System Owner
a '�
Name
Address(if different from location)
GitylTown State Zip Code
2� c 0
Telephone Number
A
.B. Pumping Record
I 1- 4, r
1. Date of Pumping Date 2. Quantity Pumped: Gallons ---�
3. Type-of.system: ❑ Cesspool(s) El Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 3/No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company _
7. Lo it-ere ontents were disposed:
GLSI-P Lowell Waste Water
Sign a Naule pate `
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