HomeMy WebLinkAboutSeptic Pumping Slip - 120 WINDKIST FARM ROAD 10/16/2017Commonwealth of Massachusetts
City/Town of.
System Pumping - Record
Form 4
C
gill
lows OF 14,0VM-I ANDOVER
VOA:5H DEPPaIMENT •
•
DEP has provided this form for usety local Boards Of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this forrn, 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 Information
1. System Location: Left/ Right front of house ightgaeof 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
State
(4k-kAe,L)—<4
Zip Code
Name.
Address (if different from location)
City/Town '
Stat c Zip Codeq
cr
Telephone Number
B. Pumping Record
C'e -
1. Date of Pumping
Date
2. Quantity Pumped:
3. Type -of system': 0 Cesspool(s) 2-<-:tic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present?
5. Condition of System:
Gallons
if yes, was it cleaned?
Ehle-CEI No,
CcDs
System Pumped By:
Neil Batesbn
Name
Bateson Enterprises Inc
Company
7. Location where contents•were disposed:
"S./) Lowell Waste Water
SigntuFeqHauIe
F5821
Vehicle License Number
Date
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