HomeMy WebLinkAboutSeptic Pumping Slip - 100 FOSTER STREET 5/24/2017Commonwealth of Massachusetts
City/Town of
ystern Pu p ec
IAY 24 2017
Fo 4 TOWN Of. r4oN 11 ANDOVER
HEALTH 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 Info
I I
ation
1. System Location: Left / Right front of house, Left / Right rear of hous
Right side of building, Left / Right frOnt of buildirig, Left / Right rear of building,
2. System Owner:
eC)
)rittsidedfjiotse, Left /
Address (if different fromfrorn ocation)
City/Town
Telephone Numb r
P g
1. Date Date of Pumping
3. Type of system':
c
0 Other (describe):
4. Effluent Tee Filter present? 0 Yep
Date
2. Quanti ,,Pumped:
Cesspool(s) eptic Tank
Gallons
0 Tight Tank
' 5. Condition of System:
6: System Pumped By:
Neil. Bateson
• Name
Bateson Enterprises Inc
Company
7. LocatiorkiWII re ntentswere disposed:
a
o ell Waste Water
Sin Haule
If yes, was it cleaned? 0 Yes 0 No,
F5821
Vehicle License Number
Date
t5form4.docp 06103
System Pumping Record Page 1 0 1