HomeMy WebLinkAboutSeptic Pumping Slip - 68 CRICKET LANE 11/7/2017 a
Commonwealth of MassachusettsRECEIVED
_ Citk/Town of
i C NV ] Fi �10
System Pumping-
Record
'
FormTOWN OF NOR11i ANDOVER
DEP has provided this form for use-by local Boards of Health. Other forms may be bsed, but the
information,must besubstantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Inforrirgation.
1. System Location: Left/Right front of house, Left/Right rear of house, Left/rig j side of hoes , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under'Side
c
Address
City/Town state Zip Code
2. System Owner.
,)V N C
Name
Address(if different from location)
cityrrown State de ;
F 5,
Telephone number
.B. Pumping Record
1. Date of PumpingDate 2. Quantity Pumped:
Gallons r^``
3. Type-of system: ® Cesspool(s) p it c Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter resent?
• p ® Yep a if yes, was it cleaned? Yes Na �
6. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
r S: Lowell Waste Water
f
SignAtufe Haul date
t5form4.doc>06/03 System Pumping Record•Page 1 of 1