HomeMy WebLinkAboutSeptic Pumping Slip - 105 WINTERGREEN DRIVE 1/17/2017Commonwealth of Massachusetts
City/Town of
yste Pumpin ecord
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'OWN NUH I H ANDOVER
DEPARTMENT
DEP has provided this form for usety 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 I formatio,
1. System Location: Left / Right front of house, Left / Right rear of house, Left / ieofhousi), Left /
Right side of building, Left / Right front of buildirig, Left / Right rear of building, Under deck
2. System Owner:
Address (if different from location)
City/Town
Telephone Number
pu,, pi g ec d
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system.: 0 Cesspool(s) er--Sic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? 0 Ye
" 5. Condition of §)/stern:
6: System Pumped By:
Neil Bateson
If yes, was it cleaned? 0 Yes El No,
0 (A
' Name
Bateson Enterprises Inc
Company
7. Location. where contents were disposed:
a Lowell Waste Water
F5821
Vehicle License Number
t5form4.doc• 06/03 System Pumping Record Page 1 of 1