HomeMy WebLinkAboutSeptic Pumping Slip - 40 NORTH CROSS ROAD 9/11/2017 Commonwealth of Massachusetts
r C4/"Town of . RECEIVED
SY.4temi Pumping.Record
H" 0 7 2017
Form 4
TOWN OF NCIKM ANDOVER
DEP has provided this form`for use=by local Boards of Health. other forms may s b� e
information,must be substantially the same as that provided here. Before using.this form., '
heck with your j
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 InforMation
I. System Location: Left I Right front of house, Left i reit ear ofh e i Left/right side of house, Left/
Right side of building, Left/Right front of building, L-e g r a(buildmg, Under deck
Address
CitylTown � state Zip Code
i
2. System Owner.
Mdame'
Address(if different from location)
Citylrown State Zip Code f
Telephone Number
Pumping R-pcord �
1. Cate of PumpingDate 2. Quantity Pumped:
Gallons -T
3. T e•of s stem:
Type-of y• ® Cesspool(s) eptic T na k D Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes 0116 If yes, was it cleaned? ❑ Yes ❑ No, l
` 5. Condition of System: � .----�
6. System Pumped By.,
Neil.Batesbn F5821
Name Vehicle L lcense Number j
Bateson Enterprises Inc-
Company
7. Location wee contents-were disposed:
S. Lowell Waste Water
SigWe Date
15form4.doc»06/03 System Pumping Record•Page 1 of 1