HomeMy WebLinkAboutSeptic Pumping Slip - 86 SHERWOOD DRIVE 5/24/2017Commonwealth of Massachu
City/Town of
yst m •u ecord
CE V
• MAY 2 4 Z017
TOWN. OF NOK 1.1 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 Informatior.
1. System Location: Right ont of hous , 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
Address
City/Town
2. System Owner:
Address (if different frorn location)
City/Town
P
1. Date of Pumping
. Type.of system':
ecord
0
Da
Cesspool(s)
Other (describe):
4. Effluent Tee Filter present? 0 Yes o
" 5. Condition of System:
: System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Lo
Sign
ere contents were disposed:
Lowell Waste Water
/
State
Telephone Number
Zip Code
uantity Pumped: Gallons
eptic Tank 0 Tight Tank
If yes, was it cleaned? IJ Yes C] No,
e-cickiL
F5821
Vehicle License Number
Date
t5forrn4.doc* 06/03 System Pumping Record * Page 1 of 1