HomeMy WebLinkAboutSeptic Pumping Slip - 131 GRANVILLE LANE 12/28/2016 n • f
I n of RECEIVED
YS
4 TOWN OF NORI ANDOVER
i-1EAL. i 1DE 'alG�I'Mi:�:NI'
DEP has provided this form for use.by local Boards of Health. Other forms may,e 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 forrn they use.The System pumping Record must be submitted to
the local Board of Health or other approving authority.
A. FacflO ty Information
t. System Location: LatiC/Right front of house, Lei/Right rear of hour Le` righ e bf ham, Left f
Right side of building, Left I Right front of building, Left I Right rear of building, Under ecic
Address
itylrown State Zip code
. System Owner
Name'
Address(if different from location)
cityfrovwn stat . ip cod
5 Telephone Number
Pumping
1. Date of Pumping Date udntity Pumped: Gallons
. Type•of systerr<: ] Cesspool(s) eptic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yep v If yes, was it cleaned? El Yes No,
. Condition of.System: ,
6: System Pumped 6y.,
Nell.Batesbn P5321
Name Vehicle License dumber
gate�on �r�terprises Inc
Company
7. Lo t rn- , re contents-were disposed.
L'S: Lowell Waste Water
Sign a Houle >'�te
t5f'orm4.doam 06/03 system Pumping Record Page 1 of 1