HomeMy WebLinkAboutSeptic Pumping Slip - 133 COLONIAL AVENUE 10/16/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
• RECEIVE
c1,
1(MM OF MORT ANDOVER
RE111;1110EPAI1VMENT
DEP has provided this form' for use.by local Boards Of Health. Other forms may be Used, but the
informationmust be substantially the same as that provided here. Before using.this Rim), 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, Left 1;;--- hoki.si 4, Left/ right side of house, Left /
Right side of building, Left / Right front of building, Left / Ri1itr of building, Under deck
Address
City/Town
2. System Owner
Address (if different from location)
City/Town
State;
Zi
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
3. Typedf system: D Cesspool(s)
0 Other (describe):
2. Quantity Pumped:
1-21.43e1(c Tank Ej Tight Tank
Gallons
9.-------------
4. Effluent Tee Filter present? Ej Yes No if yes, was it cleaned? 0 Yes El No,
5. Condition of System:
•\‘‘ -----tc:4A-4c
6: System Pumped By:
Neil Bateson •
' Name
Bateson Enterprises Inc
Company
7. Loca 'on -where contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
5form4.doc. 06/03 System Pumping Record • Page 1 of 1