HomeMy WebLinkAboutSeptic Pumping Slip - 317 RALEIGH TAVERN LANE 11/17/2017 RECEIVED
Commonwealth of Massachusetts
v
Citji'JTown of
System Pumpin§.IRecordi ANDOVER T(DWN OF NOMI
-HIEALTH[DEPARTMENT
Form 4
DEP has provided this form for use-by local Boards of Health. Other 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 Locatio • Le / ti ht fro a W
y g nt of house deft/Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Righ ron of buildlrig, Left/Right rear of building, lender deck
Address
i
sa-
�� .
C4ty/Town Skate Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' State- Zip Code r�
Telephone Number
. Pumping Radar
1. Crate of Pumpingdate f Quantity Pumped: Gallons .
s' I
3. Type of system: ❑ Cesspool(s} . Septic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was It cleaned? Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Nell.Bateson- F5821
Name Vehicle License Number
Bateson Enterprises inc-
Company
i
7. Location whe contents-were disposed:
Ca S. Lowell Waste Water t
I ?
Sign a 9t HiwlarU Date
15form4.doc 06/03 System Pumping Record.Page 1 of 1