HomeMy WebLinkAboutSeptic Pumping Slip - 11 BRIDGES LANE 11/7/2017 Commonwealth of Massachusetts
.City/Town of RECEIVED
Sy�tern Pumpmg.IRecor �,
Farm 4 "TOWN OF NOFM ANDOVER
HEALTH LEr'AR"MEN'r
DEP has provided this form for use�by local Boards of Health. Quer forms maybe*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. Information
1. System Location: Left/Right front of house, Left 1 i ht rear of house?Left/right side of house, Left f
Right side of Building, Left/Right front of buiidirig, Left fight rear of building, Under deck
. Address
City/Town State Zip Code
Z. System Owner:
Name'
Address(if different from location)
City/Town ' Stater Z .�
Telephone Number
,i
. Pumping !Record
1. Date of Pumping Date 2. Quantity Pumped:
�
-� Gallons }---t�
3. Type-of system: ® Cesspool(s) p8 "tic Tank (I Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? 0 Yes ❑ No,
' 5. Condition of System• .
'c
111J
6. System Pumped By: l
Neil.Bateson ' 1=5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. La on here contents-were disposed:
CLS: Lowell Waste Water
signAt4e cf HaulaV Date
5form4.doc•06/03 System Pumping Record•Page 1 of 7