HomeMy WebLinkAboutSeptic Pumping Slip - 242 FOSTER STREET 5/24/2017Commonwealth of Massachuse
City/Town of . •
yste on • 11- ecor
Fo 4 TOWN Oh NOR I-1 ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for usetiy 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 Inf
at o,
1. System Location: Left/ Right front of house, Left /
MAY 2,1 2017
, Left/ right side of house, Left /
Right side of building, Left / Right frOnt of building, Left / Right rear �f building, Under deck
2. System Owner:
Name.
Address (if different from location)
CIty/Town
Telephone Number
p
R
c d
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: Ej Cesspool(s) 0—Siptic Tank Tight Tank
El Other (describe):
4. Effluent Tee Filter present? 0 Yap alcio
If yes, was it cleaned? 0 Yes DI No,
" 5. Condition of System:
et/
6. System Pumped By:
Nell. Bateson
' Name
Bateson Enterprises Inc
Company
ere contents were disposed:
Lowell Waste Water
PP
ign, Date
F5821
Vehicle License Nu b r
t5forrn4.doc• 06/03 System Purnping Record • Page 1 of 1