HomeMy WebLinkAboutSeptic Pumping Slip - 21 ASH STREET 5/24/2017Co monwealth of Massach se
City/Town of
yste m
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Fo 4
n
ec
rd
MAI 2 ' 2017
TOWN. OF Nov.( irt ANDOVER.
HEALTH DEPARTMENT
DEP has provided this form' for use=by 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 Infor
I
ation
1. System Location: Left / Right front of hous
ighIear of houslfi,) Left / right side of house, Left /
Right side of building, Left / Right front of bus mg, Left / FliVfit rear of building, Under deck
Address
e
City/Town
2. System Owner:
State
Name
Address (if different from location)
City/Town
1. Date of Pumping
3. Type of system':
0 Other (describe):
4. Effluent Tee Filter present? El Yes
5. Condition of By e
Telephone Number
Date 2. Quantity Pumped:
Gallons
Cesspool(s) a -Septic Tank 0 Tight Tank
If yes, was it cleaned? 10 Yes 0 No,
6: System Pumped By:
Neil, Bateson
' Name
Bateson Enterprises Inc
Company
7. Locajpww1,er� contents were disposed:
GL S. LoweH Waste W
F5821
Vehicle License umber
t5fonn4.doc. 06103 System Pumping Record Page 1 of 1