HomeMy WebLinkAboutSeptic Pumping Slip - 459 SALEM STREET 5/15/2017Comm° wealth of Massachusetts
City/Town of.
Ote ping ec
1,1111,
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Vit41,1 OF NOR II ANDOVER
bEALIFA DEPARTMENT
DEP has provided this form- for useby 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 formaton
1. System Locatio •
Right side of bui
City/Town
2. System Owner:
front of ho
/ Ribliffro
Left/ Right rear of house, Left./ right side of house, Left /
building, Left / Right rear of building, Under deck
Address (if different from location)
City/Town
P
c
Telephone Number
. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system': E Cesspool(s) eptic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present?
. Condition of Sys -rp
6: Systeni Pumped By:
Neil. Bateson •
' Name
Bateson Enterprises Inc
Company
7. Loca,jere contents were disposed:
Lowell Waste Water
If yes, was it cleaned? Erreilp No,
F5821
Vehicle License Number
t5form4.doc. 06/03 System Pumping Record Page 1 of 1