HomeMy WebLinkAboutSeptic Pumping Slip - 11 BARCO LANE 5/24/2017Commonwealth of Massachusetts
City/Town of
yste Pu pin Lb• ecore
I 11 I
2 11 2 011
TOWN O NUK Y. 11 ANDOVER
1-1EALTH DEPARTMENT
DEP has provided this form for usellf 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 yo r
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 Infix'
atio
1. System Location: Left / Right front of house, Left / Right rear of house, Left/ right 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
State
Address (if different fram location)
City/Town
1. Date of Pumping
3. Type.of system':
Ej Other (describe):
4. Effluent Tee Filter present?
' 5. Condition of s em:
• —
Telephone Number
I
Date 2. Quantity Pumped:
Cesspool(s) 111.--80-tcrank 0 Tight Tank
Yes
Gallons
If yes, was it cleaned? 0 Yes ID No,
6: System Pumped By:
Nell Bateson
' Name
Bateson Ente
Company
rises Inc
7. Loction,wre contents were disposed:
a
SignHaul
owell Waste Water
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1