HomeMy WebLinkAboutSeptic Pumping Slip - 39 GRANVILLE LANE 1/17/2017Commonwealth of Massachusetts
Cityrfown of
yste Pm ping Record
Fo 4
MN ?017
ORTH ANDOVER
DEPARTMENT
DEP has provided this form. for use.by iocal Boards Of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this forrn, 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 infor iation
1. System Location: Left / «ght front of hou--- Left / Right rear of house, Left / II ht side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
City/Town
2. System Owner.
Name'
Address (if different from location)
City/Town
P
g Record
Date of Pumping
. Type of syttem:
EJ Other (describe):
4. Effluent Tee Filter present? 11 e Ell No
5 Condition of System:
Telephone Number
c)-8
2. Quantity Pumped: Gallons
Date
Cesspool(s)
ptic Tank Ej Tight Tank
lf yes, was it cleaned? [3--Y61-n No
6; System Pumped By:
Nell. Bateson
• Name
Bateson Enterprises Inc
Company
7. Locati n where conte
ts were disposed:
Lowell Waste Water
F5821
Vehicle Li
Date
Number
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