HomeMy WebLinkAboutSeptic Pumping Slip - 22 FULLER ROAD 11/21/2017 RECEIVED
: ,, Commonwealth of Massachusetts
City/Town of
stein Pumping.RecorT(,)WN OF N0KfH ANDOVER
d
Form 4
DEP has provided this form far usewby focal Boards of Health. Other form's may•be•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 for(h they use.The System Pumping Record must be submitted.to t
the local Board of Health or other approving authority. I
A. Faciility, Information .
i
9. System Location:K )`Rig tit`o , Left Right rear of house, Left/right side of house, Left't
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
L
City/Town State Tip Cotle
2, System Owner:
Name'
Address(if different from location)
City/Town ' State Zip Code
F Telephone Number
r
1
. Pumping Record l
9. Date of Pumping sate 2. Quantity Pumped: Gallons
3. Type-of system: El Cesspool(s) otic Tank
E] Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yep o If yes, was it cleaned? ❑ Yes F—I No,
" 5. Condition of System: A / �
1
6. System Pumped By:
Nell.Bateson " F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. 7G,
r+,w ere contents-were disposed:
S: Lowell Waste Water
` f
Sign a Haule pate
t5form4.doc•06103 System Pumping Record•page 9 of 1
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